Unicef - Community Led Total Sanitation

Second Review of
Community-Led Total Sanitation

in the East Asia and Pacific Region
Regional Report
December 2015
Review supported by
Contents
Second Review of
Community-Led Total Sanitation

in the East Asia and Pacific Region
Regional Report
December 2015
i East Asia and Pacific Regional Report

Contents
2016 UNICEF/EAPRO East Asia and Pacific Regional Office,

19 Phra Atit Road, Bangkok 10200, Thailand
Tel: +66 2356 9274
www.unicef.org/eapro
All cover photos UNICEF
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Foreword
This review is aimed as a timely contribution to overall knowledge on the provision of equitable and
sustainable sanitation and hygiene for all highlighting what has worked, and issues that still need
attention, especially in the area of Community Led Total Sanitation (CLTS).
Sustainable Development Goal 6 addresses the goal of universal access to safe drinking water,
sanitation and hygiene, with proposed targets (by 2030) to eliminate open defecation; achieve universal
access to basic drinking water, sanitation and hygiene for households, schools and health facilities; to
halve the proportion of the population without access at home to safely managed drinking water and
sanitation services; and to progressively eliminate inequalities in access. UNICEFs Strategic Plan
(2014-2017), has also set out to significantly reduce open defecation and to improve overall WASH access
in communities and schools, in support of childrens health and nutrition outcomes.
According to UNICEFs State of the Worlds Children (2012), nine countries in East Asia Pacific have
more than 30% stunting prevalence rates; around 659 million people are without access to improved
sanitation, and disparities in communities and schools are stark. Around 83 million people in the region
still practice open defecation, with three countries (Indonesia 51 million, China 14 million and
Cambodia 7.4 million) being among the 12 in the world with the largest populations practicing
open defecation.
Similarly, maternal and child malnutrition rates remain high across parts of the region, with eight
countries reporting stunting prevalence of above 30 per cent (Cambodia, Indonesia, Lao PDR, Myanmar,
Papua New Guinea, Philippines, Solomon Islands, Timor-Leste). An estimated 28 million children under
five years old are stunted. This is especially troubling since a growing body of evidence establishes the
linkages between sanitation and stunting, indicating that children in unhygienic environments will not
reach their full growth potential even when food is sufficient.
Community Led-Total Sanitation is being implemented in more than 50 countries around the world,
including 12 countries in this region. Recognizing the key role CLTS plays in overall efforts for improving
sanitation and hygiene behavior, this 2nd Regional Review of Community Led Total Sanitation provides
insights on progress and highlights challenges and areas for attention in order to achieve results at scale.
This report benefited greatly from the generous contributions of partners from WSP, Plan International,
WaterAid Australia, the Australian Government and other development partners from each of the
countries covered under this review. This report compiled by the Water Sanitation and Hygiene team in
UNICEFs Regional Office for East Asia Pacific is a response to the Global Community Approaches to
Total Sanitation (CATS) evaluation (undertaken in 2014 by UNICEF NYHQ Evaluation Unit). Produced as
a response to request by partners, we trust it is a useful contribution for all.
Wivina Belmonte Chander Badloe

Deputy Regional Director, UNICEF Regional Adviser - WASH, UNICEF
East Asia and Pacific Regional Office (EAPRO) East Asia and Pacific Regional Office (EAPRO)
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Acknowledgements
This second regional review of the Community Led Total Sanitation (CLTS) in the East Asia and the Pacific
region was commissioned by UNICEF East Asia and the Pacific, and supported by WaterAid Australia,
the World Bank Water and Sanitation Program, and Plan International. This report has been produced
based on experiences and lessons on the implementation of Community Led Total Sanitation (CLTS)
from Cambodia, China, DPR Korea, Indonesia, Kiribati, Lao PDR, Mongolia, Myanmar, the Philippines,
Papua New Guinea, Solomon Islands, Timor-Leste, Vanuatu and Viet Nam.
Special appreciation is expressed to the many UNICEF, WSP, WaterAid, Plan International colleagues,
and those colleagues at the country levels, for generously providing their time and efforts in collecting
the country level data on CLTS implementation and for undertaking reviews of the draft country profiles.
Additional thanks goes to those specialists who shared their knowledge and experience towards the
nine case studies, with acknowledgment to the workshop participants in Cambodia; IUWASH,
the development partner and government colleagues interviewed in Jakarta and selected provinces in
Indonesia; World Vision in the Solomon Islands; and for all those met in the Philippines (see Annex 2
for details on Country Review Teams and other contributors).
This 2nd review was initiated by and completed under the overall guidance and coordination from
Chander Badloe Regional Adviser WASH, UNICEF East Asia and the Pacific Regional Office. UNICEF
is extremely grateful to Penny Dutton, Water and Sanitation consultant, who undertook this review across
14 countries and multiple partners in the region, and who prepared this report. Finally, we would also like
to acknowledge the financial support from Bill & Melinda Gates Foundation (BMGF), the Department for
International Development (DFID) and Government of Australia through the Department of Foreign Affairs
and Trade (DFAT) for this review and publishing this document.
Data sources and notes

Main sanitation dataset: from Progress on Drinking Water and Sanitation: 2015 Update, from WHO/
UNICEF Joint Monitoring Programme for Water Supply and Sanitation (JMP).
Country-specific data: from interviews and contributions from country teams.
Case study data: from secondary sources, interviews and contributions from key informants in case
study countries.
UNICEF does not warrant that the information contained in this publication is complete and correct and
shall not be liable for any damages incurred as a result of its use.
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Contents
Acronyms vi
Executive summary vii
PART I
1 Introduction 2
2 Objectives 3
3 Methodology 3
4 Global and regional update 7

4.1 UNICEF CATS 7
4.2 Plan International Post ODF and CLTS Sustainability Study 9
4.3 IDS sustainability and CLTS 10
4.4 Sanitation and stunting 11
5 Findings 13
5.1 Country contexts 13
5.2 Country CLTS overviews 15
5.3 CLTS Scorecard 21
5.4 Regional CLTS progress overview 31
5.5 Key issues 33
6 Conclusions 40
References 42
PART II
ANNEX 1: Country CLTS overview 44

ANNEX 2: Country review teams and other contributors 138
ANNEX 3: Data from regional CLTS review 140
ANNEX 4: Case studies 141
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Acronyms
EAP East Asia and Pacific
EASAN East Asia Ministerial Conference on Sanitation and Hygiene
CATS Community Approaches to Total Sanitation
CBO community-based organization
CLTS Community-Led Total Sanitation
CR-SHIP Global Sanitation Fund Cambodia Rural Sanitation and Hygiene Improvement Program
DFAT Department of Foreign Affairs and Trade
DHS Demographic and Health Survey
DSWD Department of Social Welfare and Development (the Philippines)
iDE International Development Enterprises
INGO international non-governmental organization
IUWASH Indonesian Urban Water, Sanitation, and Hygiene
JMP WHO-UNICEF Joint Monitoring Program for Water Supply and Sanitation
LGU local government unit
MICS Multiple Indicator Cluster Survey
MDG Millennium Development Goal
MoH Ministry of Health
NGO non-governmental organization
ODF open defecation free
PAKSI Community Action Plan for Sanitation and Hygiene (Timor-Leste)
PhATS Phased Approach to Total Sanitation
RWSSH Rural Water Supply, Sanitation and Hygiene
STBM Sanitasi Total Berbasis Masyarakat, Community Based Total Sanitation (Indonesia)
SNV Netherlands Development Organisation
UNICEF United Nations Childrens Fund
USAID US Agency for International Development
WASH Water, Sanitation and Hygiene (Sector)
WHO World Health Organization
WSP World Bank Water and Sanitation Program
ZOD Zero Open Defecation
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Executive summary
Introduction
Despite rapid economic growth, inadequate sanitation and hygiene remain significant problems in the
East Asia and Pacific (EAP) region. Several countries have fallen short of their MDG sanitation targets,
and continue to have high open defecation rates. Around 83 million people in the region still practice
open defecation, with three countries from this region (Indonesia 51 million, China 14 million and
Cambodia 7.4 million) being among the 12 countries in the world with the largest populations practicing
open defecation.
Community-Led Total Sanitation (CLTS) is an approach used by 12 countries in this region (Cambodia,
China, Indonesia, Timor-Leste, Kiribati, Lao PDR, Viet Nam, Myanmar, the Philippines, Mongolia, Solomon
Islands, Papua New Guinea). This review of CLTS in the region, supported by UNICEF, Water and
Sanitation Program World Bank, Plan International and WaterAid, builds on an earlier review in 2012/3.
Its aim is to examine and report progress on key areas of CLTS implementation, spread and scale,
as well as provide some insights through case studies on CLTS practice in selected countries.
Methodology
The regional CLTS review was conducted both remotely (through interviews and a questionnaire) and
through in-country visits to gather data for case studies. It was made possible through review teams
established in each country primarily comprised of UNICEF, WaterAid, WSP and Plan WASH
specialists with additional assistance from key government staff, NGOs, and other development
partners in some countries. A country CLTS status update was prepared for each of the 14 review
countries, which highlights the changes since 2012. The information in these country status updates
formed the main basis for the regional analysis. Nine cases studies were prepared on varying aspects
of CLTS implementation ranging from: urban CLTS, CLTS in post emergency settings, sanitation
marketing, and techniques for verifying Open Defecation Free status.
Review challenges
The review requires organizing and managing a vast amount of data from multiple review teams for
14 country status updates and nine case studies. Few countries have monitoring systems which can
produce reliable quantitative data on the number of communities triggered and ODF achievements,
so figures in the report may under or overestimate the true situation.
Key findings
CLTS continues to play an important role in achieving reduction in open defecation and the uptake
of sanitation in the region, but accurately quantifying that contribution is difficult. Indonesia has a
functioning monitoring system and a basic calculation shows that the 3,140 villages that achieved ODF
status between 2012 and 2015, using CLTS as part of a broader government rural sanitation program
(STBM), contributed most of the gains to the 4,000,000 people who ceased open defecation between
2012 and 2015 (from JMP estimates).1
CLTS is also contributing to village-wide sanitation coverage, which, from a growing number of studies,
including within the region, correlates with protection against environmental enteropathy or leaky gut
syndrome in young children. Environmental enteropathy appears to be a significant cause of infant
and child stunting far more serious than diarrhoea. CLTS is a particularly appropriate sanitation
approach because it aims for village-wide elimination of open defecation a requirement for combating
environmental enteropathy.
1 Assuming an average village size of 1,500 people.
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Over the last three years there has been greater recognition at government level of CLTS as a viable
approach; evidenced by the embedding of CLTS in sanitation policies and strategies. Eight of 12
implementing countries have policies that recognize and promote CLTS, compared to three countries
previously. The development of implementation guidelines and ODF criteria to help institutionalize CLTS
as a common consistent approach have occurred, along with the standardization of facilitator training.
The main drivers for scaling up CLTS were: government support, for example Indonesia has triggered
25,000 communities an impossible feat without CLTS being a government programme; external
funding such as the Global Sanitation Fund in Cambodia; and clarity and consistency in methods such
as standardized facilitator training, ODF guidelines, etc. The number of organizations supporting CLTS
implementation or directly implementing CLTS is not necessarily a driver, but rather the quality of those
organizations is. A countrys early adoption of CLTS is also not a prerequisite for scale as evidenced by
the progress of countries such as Kiribati who have recently taken up CLTS.
Promising new developments and trends in CLTS include:

Application of modified CLTS in urban areas;
CLTS in post emergency situations;
Better targeting of the poor, for example, through social welfare programmes which
integrate sanitation;
Efforts for improving the sanitation supply side, for example, through promotion of
sanitation marketing;
Ongoing attempts at integrating CLTS with nutrition programmes regarding interventions on hygiene
promotion, hand washing and other hygiene behaviours, WASH in schools; and
The use of microfinance to help the poor.
However challenges remain which need to be addressed:

Governments are not doing enough to finance CLTS in many cases, governments are not backing
CLTS by funding implementation, monitoring and knowledge sharing.
Poor strategies exist for rolling out sanitation, including reaching ODF goals. There is often a
disconnect between the political targets for sanitation and the practicalities of reaching those targets
through CLTS.
The extent to which sanitation monitoring systems are adequate in capturing data on the
implementation progress of CLTS and the number of ODF communities, especially in forthcoming
SDGs and universal access contexts. With regards to CLTS, it also seems important to focus on the
practice of CLTS (e.g., from triggering to follow-up with communities in becoming ODF, follow-up
monitoring on slippage, ensuring inclusiveness/participation, etc.).
ODF verification and certification processes, together with ODF criteria, are still lacking in some
countries, and no country has addressed post ODF follow up.
More work is needed on integrating CLTS with sanitation marketing and improving access to
sanitation products and services that meet different needs.
Sanitation and CLTS in challenging environments, e.g., flood prone areas, high water table areas and
disaster prone areas are yet to be tackled at any scale, despite many people in the region living in
challenging environments.
No country has systematically adopted pro-poor support processes within CLTS yet, although some
are experimenting.
Reliable information about the cost of CLTS is absent. Without this information, it is difficult to
advocate to governments that CLTS is a cost effective approach which should be supported.
CLTS is seen as a largely rural approach to sanitation, yet urban populations are growing in the
region and have considerable sanitation challenges with increasing poor populations and higher living
densities. The challenge is how to take the demand creation aspect of CLTS and adapt the approach,
combined with sanitation solutions and business models to make it fit to an urban context.
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CLTS information sharing within the region is ongoing, however this could still be further
strengthened. Unfortunately, there has not been a continuation of the East Asia Ministerial
Conference on Sanitation and Hygiene (EASAN), which in the past, provided the opportunity for
regional sanitation exchange events. On the other hand, several organizations have continued
undertaking exchanges/learning events/study tours, indicating the need for more opportunities for
the sharing of practices and paired learning between countries with similar levels of development and
CLTS implementation.
Recommendations
The insights provided through this second review provide the basis for several recommendations for
further consideration. The following recommendations are considered from a regional perspective.
Generalizing about the region as a whole is not particularly helpful, given its extreme range of size
and the situations of the countries within the region, but there is diversity of experience available.
Indonesia still remains the largest implementer of CLTS and there is much to learn from this country
in terms of government approach, monitoring, scale of triggering and ODF communities. However,
Indonesias persistently high open defecation and child stunting rates suggest that Indonesia may
not have all the answers, despite it having a rich range of experiences. New and emerging countries
implementing CLTS may provide fresh insights.
CLTS continues to be effective through its core attributes of triggering behaviour change and
generating collective action. But is there a risk of CLTS fatigue and a loss of interest in the approach in
future? Or is it that CLTS becomes so much a part of the way sanitation is achieved that it is no longer
singled out as an approach? Ultimately this will depend on each country and their own dynamic.
The following are additional observations regarding the improvement of CLTS.

Implementation has been most effective where governments have supported CLTS but can excel with
government commitment to funding, capacity building and accountability.
A greater effort is needed in monitoring CLTS processes and sanitation access, and documenting and
sharing successes (and failures) of CLTS implementation.
As gains are made on sanitation targets, the hardest to reach and most marginalized communities
will be the most difficult to reach. Options to integrate CLTS within sanitation solutions in challenging
physical environments for the very poor, and in remote locations, should be explored sooner rather
than later.
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PART I
1INTRODUCTION
PART I 1Introduction
Despite rapid economic growth, inadequate sanitation and hygiene remain significant problems in the
East Asia and Pacific (EAP) region. Several countries have fallen short of their Millennium Development
Goal (MDG) sanitation targets, and continue to have high open defecation rates. An estimated 519
million people in the EAP region remain without access to improved sanitation. Glaring disparities
between urban and rural populations, poorest and richest quintiles prevail. Around 83 million people in
the region still practice open defecation, with three countries from this region (Indonesia 51 million,
China 14 million and Cambodia 7.4 million) being among the 12 countries in the world with the largest
populations practicing open defecation.
Community-Led Total Sanitation (CLTS) is a widely used approach with 602 countries worldwide now
adopting it, including 12 countries in this region (e.g., Indonesia, Cambodia, Timor-Leste, Kiribati,
Lao PDR, Viet Nam and Myanmar).
Recognizing the important role CLTS plays in eliminating open defecation and for improving sanitation and
hygiene, a regional review was undertaken in 2012/2013 to better understand: how CLTS implementation
was working in this region; why progress differs across and within countries; and what more could
be done to support, improve and scale up CLTS as part of wider approaches to achieve sanitation and
hygiene objectives within the region.
The review resulted in a comprehensive up-to-date status of CLTS, lessons and experiences from this
region, and as such, helped in accelerating efforts for reaching open defection free (ODF) status, and
for maintaining a high level of focus on sanitation and hygiene. The review data showed that CLTS did
scale-up well in two early adopting countries, with Cambodia and Indonesia triggering 2,000-7,300 rural
communities; and revealed that Myanmar joined the five mid-term countries in implementing CLTS
in 200-850 rural communities since 2008. Little progress was noted outside of these eight countries
due to the recent introduction of CLTS in Mongolia, Solomon Islands and Kiribati, and the ongoing
re-introduction of CLTS in China. The review confirmed that CLTS is working in East Asia and the Pacific.
CLTS has already spread to 12 countries, triggered sanitation improvements in more than 12,000 rural
and peri-urban communities, and led to more than 3.1 million people living in 2,300 ODF communities.
Country level implementation of CLTS is still ongoing and being intensified. A regional learning event on
Scaling-up sanitation and hygiene in EAP, organized jointly with the World Bank Water and Sanitation
Program (WSP), UNICEF, Plan International and WaterAid in December 2013, provided an opportunity for
countries from the region to share their progress and plans. Both the regional review and the regional
learning event recognized the need for the documentation of lessons and sharing, and emphasized
the need for more detailed knowledge on certain areas and on how best to strengthen CLTS enabling
environments, improve CLTS effectiveness, tackle sustainability concerns, complement CLTS with other
approaches such as Sanitation Marketing, and accelerate scaling up. Similar challenges and needs were
also highlighted during the CLTS workshop prior to the 37th Water, Engineering and Development Centre
(WEDC) international conference held in September 2014.
2 http://www.communityledtotalsanitation.org/where
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2OBJECTIVES
PART I 2Objectives
The main objectives of this 2015 review of CLTS in the EAP region are to:
Update the 2012/2013 Regional Assessment:

This review aims to examine and report progress on key areas such as CLTS spread, data quality and
availability, CLTS scale-up timelines, impact on national sanitation coverage, CLTS influence on national
policies, strategies or action plans, sustainability, verification and monitoring, and capacity for scale-up in
14 countries in the region.3 It also examines some of the latest literature around CLTS implementation,
sanitation and hygiene behaviour improvements, and their impact on achieving health and nutrition
outcomes.
Develop comprehensive country-specific case studies:

The review aims to document, through in-depth case studies, the status of CLTS in selected countries,
highlighting progress, challenges and lessons learned. The comprehensive country case studies examine
areas with strong demand for more detailed knowledge in order to inform other countries in the region of
CLTS implementation practice and to scale issues of relevance.
3METHODOLOGY
Stakeholder engagement
The regional CLTS review was carried out both remotely (email, Skype, etc.) and in person through
country case study research visits to several countries in the region. The review was only made possible
by the considerable assistance provided by many stakeholders and contributors in each country. Country
review teams were established during the inception phase to provide technical input and guidance on
their country CLTS status update. Review teams primarily comprised of the United Nations Childrens
Fund (UNICEF), WaterAid, WSP and Plans Water Sanitation and Hygiene (WASH) specialists in the review
countries, with additional assistance from key government staff and other programmes or organizations
in several countries. Additional contributors were involved with the research and provision of information
for the case studies. These people included government staff, non-governmental organizations (NGOs),
specialist WASH personnel and communities themselves. Annex 2 details the composition of the review
teams involved in each country and others who contributed to case studies.
Country CLTS status updates

The standard template for the country CLTS overviews used in the 2012 Regional Review was reviewed
and formatted to a CLTS Country Status Update template. The adopted format allows the comparison of
achievements with the 2012 status, but eliminates the use of country rankings. The reasons for this are
that: (i) an ordinal ranking system does not take into account the different country situations and size, and
forces countries into a ranking relative to another country when there might be two or more countries
performing equally well (or poorly) on CLTS, all factors considered; (ii) the individual (ranked) criteria to
achieve an overall country ranking are somewhat subjective for example, the number of provinces
implementing CLTS or the number of implementers may not reveal true scale. The use of traffic light
colour coding was adopted as an alternative ranking method so that countries could be ranked equally in
different criteria rather than relatively, and blocs of poor performing countries or weak factors across all
countries could be clearly identified.
3 Cambodia, China, Indonesia, Kiribati, DPR Korea, Lao PDR, Mongolia, Myanmar, Papua New Guinea, the Philippines, Solomon Islands, Timor-Leste,
Viet Nam and Vanuatu.

Importantly, the internal comparison of a countrys CLTS progress is possible through the country status
PART I 3Methodology
update summary table. Data can be compared between the 2012 review and the 2015 review for
indicators such as the numbers of triggered and open defecation free (ODF) communities, achievements
at reducing the openly defecating population, and changes in CLTS success rates. This may be more
telling about a countrys status, and recent changes and trends, than comparing it with other countries.
This current review also directly asked countries about the most significant changes in CLTS in the last
three years since the previous review, as well as what the outlook and opportunities were for the next
three years.
Each country CLTS status update included the following sections:

i Summary table (CLTS progress) (comparing indicators reported in the 2012 review with the 2015
review note some 2012 data is from 2010)
ii WHO-UNICEF Joint Monitoring Program for Water Supply and Sanitation (JMP) rural sanitation data
(including the openly defecating population)
iii CLTS status and geographical spread
iv CLTS institutional coverage (including implementing organizations)
v Major Non-CLTS programmes
vi CLTS variations and practice
vii CLTS scale (number of ODF communities and size of ODF population)
viii CLTS capacity
ix CLTS scorecard (enabling environment, implementation and sustainability, monitoring and evaluation)
x Most significant changes since 2012
xi Lessons learned
xii CLTS weaknesses and bottlenecks
xiii CLTS opportunities in the next 3-5 years
Data for the country status updates was taken from a questionnaire comprised of 55 questions that was
circulated to each of the 14 countries, and from documents and reports provided by the country review
teams, which included programme reports, evaluations, research studies, monitoring reports, and project
publications. Draft country status updates were shared with project review teams, sometimes several
times, and follow-up clarification was done remotely, and in person wherever possible, in order to fill in
any gaps and better understand key issues.
Case studies
Case studies, that examine some of the current CLTS issues and emerging trends in more detail, have
been included in this review. This reflects the strong interest in peer-to-peer learning between countries,
explicitly expressed at the 2013 Sanitation Learning Event in Bangkok convened by UNICEF, World Bank
WSP, WaterAid and Plan International.
Initially three high performing countries were identified as potential sources for case studies, based
on an assessment from the 2012 review, namely: Cambodia, Indonesia and Timor-Leste. Due to slower
progress than expected in Timor-Leste, the Philippines was selected as the third case study.
Field visits were made to these three countries between April and June 2015. Different options for data
collection were chosen depending on the topic of the case study and the appropriate style of consultation
for the country, resulting in:
Cambodia: a one day workshop with sanitation marketing organizations and CLTS implementers to
discuss how CLTS is integrated in sanitation marketing. The workshop was held on 23 April in Phnom
Penh and attended by UNICEF, the Government of Cambodias Ministry of Rural Development, WSP,
Plan, World Vision, Netherlands Development Organisation (SNV), WaterSHED, and International
Development Enterprises (iDE).

Indonesia: a series of meetings with UNICEF Jakarta staff, UNICEF field staff and local government
PART I 3Methodology
in three regional offices (by telephone), and meetings with the World Bank (PAMSIMAS); WSP;
USAID-Indonesian Urban Water, Sanitation and Hygiene (IUWASH); Department of Foreign Affairs
and Trade (DFAT); and Plan International to discuss scaling up of CLTS and decentralization, post ODF
monitoring, as well as CLTS in urban settings.
The Philippines: meetings in Manila and field visits to Leyte Province (Tacloban area) and Quezon
Province. Meetings were held with UNICEF, WSP, the Department of Health (Manila, Leyte
Province); Department of Social Welfare and Development (Leyte Province, Quezon Province); and
Samaritans Purse. Site visits were held that included meeting with sanitation entrepreneurs, Pantiwid
beneficiaries, households in transit housing, and other households with toilets acquired through loans
or donations.
During the course of the review, other countries expressed interest in contributing case studies on
different aspects of CLTS. Data was obtained through remote and in person consultations, documents
and reports.
The result has been a rich cross section of nine case studies of varying length from Asia and the Pacific,
large agencies and NGOs, rural and urban settings as follows:
Which comes first: CLTS or sanitation marketing? Cambodia
CLTS and decentralization Indonesia
Adapting CLTS for a major urban WASH programme Indonesia
CLTS in post emergency situations The Philippines
Closing the Gap Using CLTS to Fast Track Sanitation for the Poor The Philippines
CLTS in urban areas Informal settlements in the Solomon Islands
No Golden Solution ODF is easy but sustainability is hard in Kiribatis challenging environment
Doing the ODF Two-Step Myanmar
Testing Viet Nams ODF Criteria and Certification Process.
Review limitations
The focus of the review remains firmly on rural sanitation. Much of the data and reported progress is
for rural areas, with urban CLTS only reported in special circumstances (e.g., the case study on CLTS in
urban areas in Indonesia). The reasons for this are: (i) to enable direct comparison with the 2012 data,
which is also rural; (ii) CLTS is still largely a rural phenomena; (iii) rural communities are far less likely to
have access to sanitation (e.g., access to improved sanitation in Cambodia is 88 per cent in urban areas
compared to 30 per cent for rural areas, for China the access figures are 87 per cent for urban compared
to 64 per cent in rural areas, and for Indonesia 72 per cent urban access compared to 47 per cent
rural access).
The regional CLTS review commenced in early 2015 and has been drawn out over several months. This is
partly due to the difficulty in managing responses from multiple reviewers on 14 country status reports,
and nine case studies, and the large documentation task presented by the regional report, case studies
and country updates.
Information limitations identified in the 2012 review are still relevant. ODF sustainability and slippage
remains an understudied area, with little evidence generated on this topic.
Obtaining monitoring data on triggered and ODF communities, and the number of facilitators was
surprisingly difficult. It is still the case that few countries have a centralized monitoring system where
data on ODF communities is aggregated. Data on progress was added up from individual contributors to
the CLTS review questionnaire. While double counting has been studiously avoided (e.g., ODF counts by
funders and then by implementing NGOs) there are probably some implementers whose information is
not captured in the data if they are not part of the review team.

The reporting of a communitys ODF status in this review includes self-declared ODF communities,
PART I 3Methodology
verified and certified ODF communities. To only count those ODF communities that have been officially
verified and certified would exclude those countries where there is no nationally agreed criteria for ODF
nor any verification protocol. Not withstanding that there are different ODF criteria between countries,
data from review teams are the most reliable source of information currently available, and extra time
spent on exacting the numbers would not have produced much improvement in the results. The ODF
numbers should be taken as indicative of the scale of CLTS at a fixed point in time (mid 2015).
What the exercise of asking countries to report on triggerings and ODF communities has shown is that
monitoring systems remain poor, with few countries having national databases, or even a central register
for CLTS and ODF progress coordinated by non-government entities as a first step.
Focus on ODF progress

The country CLTS overviews continue to deliberately focus on ODF achievements as the main indicator
of CLTS progress because it is both fundamental to CLTS and relatively easy to measure. ODF success
rates4 remain an indicator of CLTS progress, as achieving community-wide or a collective sanitation
outcome requires that every household and individual stops open defecation and uses a hygienic
sanitation facility one that separates human excreta from human contact. This means that interventions
have to be inclusive, and encourage approaches that reach poor and vulnerable households. It has already
been noted that CLTS interventions do not always succeed in this aim, but the ODF concept is one of the
defining characteristics of the CLTS approach and is becoming an important strategic goal for local and
national governments with the explicit objective of achieving universal sanitation coverage.
Country-level CLTS analysis

The CLTS review aggregates information at country level and synthesizes this into a regional report.
A major challenge is that CLTS is rarely implemented consistently across an entire country and there are
variations between locations and implementers. It should be noted that a country level summary of CLTS
is a snapshot of national conditions and achievements that can unintentionally exclude or downplay some
outstanding results in local areas or by particular implementing agencies. Where possible these success
stories have been documented in the cases studies or in the country status reports.
Review benefits
For a number of countries the CLTS review provided an impetus for serious reflection on performance
over the last few years. Feedback to the author from several countries (Viet Nam, Timor-Leste, Cambodia,
the Philippines, for example) showed that the review was a catalyst for gathering people to discuss
progress and identify some of the remaining bottlenecks to scaling up. This also resulted in improved
sector coordination and strengthened relationships amongst sanitation stakeholders.
This is highlighted by the case study engagement in Cambodia. The workshop on sanitation marketing
and the integration of CLTS was the first time that CLTS practitioners and sanitation marketers had been
brought together to analyse the situation in detail, despite the history of co-existence of both approaches
in the country. Feedback from participants was very positive:
It further brought home to me how little we know about where and when CLTS has been
implemented and, more critically, what influence it has on changing the sanitation landscape in
Cambodia. I agree...that CLTS can play a great role in bringing communities to 100 per cent access if
we target communities more specifically. Lyn Mclennan WaterSHED
It is encouraging to see more discussion on CLTS and Sanitation Marketing. We need to have more
consultation among relevant stakeholders. Chreay Pom, Director, Department of Rural Health Care,
Ministry of Rural Development
4 ODF success rate = proportion of triggered communities that are successful in achieving ODF status.

4 GLOBAL AND REGIONAL UPDATE
PART I 4 Global and Regional Update
The following section summarizes some of the major recent learnings in CLTS.
Since 2012, a number of the major global and regional documents available on CLTS have been published
including the UNICEF Global CATS Review 2014, Plan Internationals ODF Sustainability Study 2013, and
Plan International USA and The Water Institute at UNC Testing CLTS Approaches for Scalability (TCAS)
Project. In addition, the meeting reports from the Lilongwe Briefing 2012, Bangkok Sanitation Learning
Event 2013, and the Hanoi CLTS Sharing and Learning Workshop 2014 further inform sector development
and needs.
4.1 UNICEF CATS

UNICEF evaluated its experiences in understanding and implementing Community Approaches to
Total Sanitation (CATS)5 from when CATS was officially adopted by UNICEF in 2008 until the present.
The specific objectives were to evaluate the effectiveness, efficiency, sustainability and outcomes of
the efforts in CATS supported by UNICEF to take stock of CATS achievements globally and enable
evidence-based decision making on the further scaling up of CATS.
The findings are across four areas:
Outcome:
CATS is a successful approach adopted in 50 countries which has rapidly decreased open defecation and
reoriented the sanitation sector towards demand-led approaches, with a high level of alignment between
development partners.
The impact of CATS is constrained by the following:

Social cohesion and the strong engagement of local leaders are critical factors for success and thus
CATS is more applicable to rural areas.
The implementation of CATS in the presence of other subsidized sanitation programmes (either in
neighbouring communities or within the same community) has proven to be a major challenge for
UNICEF and its partners, especially where UNICEFs policy/advocacy work has not led to a clear
alignment of partners behind CLTS/CATS and where direct subsidies remain predominant
(e.g., Senegal, Burkino Faso). Progress in India, where the national sanitation programme has used
a subsidy-based approach for decades, shows that it is possible to instil CATS principles into an overall
subsidized framework. The constraint is more difficult to overcome where there exists a patchwork
of approaches within a country.
The availability and affordability of materials required to construct durable latrines can sometimes be a
major constraint. In many communities, there are some households who simply cannot afford to build
a latrine. This is especially the case in conditions where building latrines requires digging in rocky or
sandy soil, or extreme seasonal weather, such as flooding, renders simple structures inadequate.
CATS represents a new approach in many countries, requiring a substantial amount of trained human
capacity and other resources. In general, national and local governments in target countries do not
have the resources or capacity necessary for implementation.
5 CATS is an umbrella term used by sanitation practitioners to encompass a wide range of community-based sanitation programming including CLTS,
School Led Total Sanitation and Total Sanitation Campaigns which use nine core principals including community participation, no subsidy,
government participation, use of local materials and skills, and 100 per cent ODF as the goal.

Efficiency:
Creating an enabling environment e.g., advocacy, to re-orient local and national policies and strategies;
institutional arrangements and partnerships, especially local authorities and partnerships at the level
closest to the target communities;
Increased capacity, especially training of facilitators and trainers, which has been programmatic
national capacity building rather than short-term project oriented.
Less attention has been given to private sector participation, financing mechanisms and supply-related
issues. UNICEF needs to do more to make durable materials available for construction.
CATS programmes are relatively cost effective, especially when compared with latrine building
programmes.
Financial incentives through UNICEF contributing to the cost of training and capacity building was
important for programme success.
Diffusion to other communities through certification ceremonies and school children was effective but
unplanned and not a part of CATS programmes.
Effectiveness:
Changing social norms of the community rather than individual behaviour change was not consistently
considered, however this was an important factor in the success of CLTS. An example was
communities establishing their own rules against open defecation as early as the triggering stage.
The drivers of change are consistent across countries and rely mainly on shock and disgust as
communities come to understand the fecal-oral route of infection.
The strength of community leaders (including, in some countries, religious leaders) in mobilizing,
supporting and enforcing action by all members of the community is the second main driver of
change.
Sustainability:
Many countries do not have the monitoring systems to capture changes in social norms and the long-
term sustainability of ODF.
CATSs exclusive focus on the bottom of the sanitation ladder means that simple latrines are the entry
point to sanitation, yet households are not progressing up the sanitation ladder due to many factors
including finance, lack of community pressure, and no expectation to improve. Simple latrines are
often not physically durable.
A natural erosion of ODF status occurs over time due to newcomers to the community or the
deterioration of latrines, not because of a failure to adhere to the ODF social norm.
Monitoring of CATS implementation and ODF into the national M&E framework is occurring but
follow-up post-ODF is weak and it is not possible to measure slippage in national monitoring systems.
Other key findings around the impacts of CATS globally are presented below.
Health impacts:
Stakeholders asserted their belief in the positive impact of CATS programmes on the health status of
targeted communities. However, there is very little hard evidence to support a direct impact of ODF
on the health of the population. Existing CATS M&E systems generally do not include health indicators
through which impact can be assessed. What does change is the community opening up and more
freedom to discuss sanitation topics, and better understand the link between WASH activities and
health outcomes.

Gender impacts:
Empowerment of women and children has occurred as they now play an increased role in CATS
implementation.
CATS has improved physical safety through reduced exposure to physical and sexual violence when
openly defecating, and avoiding snakes and other animals.
Access for the poor:

Micro-financing options have been created and are successful in supporting latrine ownership by the
poor, but do not seem to be taken to scale elsewhere. Examples include Village Savings and Loans
Associations in Sierra Leone, village-managed funds to support poor families in Nepal, and some
communities in India which merge all financial awards in a community-managed fund to help support
poor families.
Private sector engagement is widely recognized as a key aspect of the enabling environment of CATS.
Private sector actors can be involved at various levels, with a few CATS programmes relying on private
sector actors as implementers. A range of private sector actors are involved in the construction of
latrines, including masons, latrine builders and shops selling building materials. However, engagement
with the private sector is far from systematic.
The potential to integrate sanitation marketing with CATS to mutually reinforce each other is being
considered by UNICEF to improve sustainability.
Financing
Collective rewards are used in a minority of countries. These rewards vary from monetary awards
(such as the Clean Village Award provided by the Government of India) to hygiene kits, bicycles and
mobile phones. There is no clear evidence that rewards improve the efficiency of CATS programmes.
On the contrary, they have been identified as counterproductive in some countries such as
Mozambique, where they have been completely abandoned: such rewards became well known in
advance and expected by communities, contradicting the no-subsidy principle of CATS and influencing
communities to move towards immediate quantitative results rather than adopting more durable,
embedded behaviour change.
4.2 PLAN INTERNATIONAL POST ODF AND CLTS

SUSTAINABILITY STUDY
Plan reviewed the sustainability of its CLTS programmes in four countries Sierra Leone, Ethiopia, Kenya
and Uganda by collecting data from 4,960 households in 116 villages which had been declared ODF
two or more years earlier. The study looked at what percentage of households remained ODF after two
years; why they remained ODF; and why some households reverted to open defecation. The first phase
of the study checked the status of nearly 5,000 households against the original ODF criteria: having a
functioning latrine, a means of keeping flies from the pit, absence of excreta in the vicinity of the house,
hand washing facilities with water and soap or a soap substitute, and evidence that the latrine and hand
washing facilities were used. The study found that 87 per cent of households had a functioning latrine,
but if all five of the criteria were applied then the overall slippage rate across the study was 92 per cent,
with only 18 per cent of households remaining ODF. The most commonly cited reasons for slippage
were financial constraints, no more support from within the community, inconvenience and discomfort,
rebuilding and emptying pits, and sharing.
The second phase of the study looked at the factors that motivated a selection of these households to
retain/maintain their latrines or abandon them. The single most significant motivator in triggering was
disgust, but after achieving ODF status, health became the main reason why households continued to be
ODF with the benefits of reduced illness, fewer health visits and reduced health costs. Enabling factors
were the availability of land and materials, as well as technical advice. Demotivating factors for openly
defecating households included a lack of money to maintain toilets and a lack of community support for
continued use, with the barriers being difficult conditions and a lack of access to finance. Households did
not move up the sanitation ladder after building their toilet and some simple latrines were not sustained.

Recommendations include strengthening the promotion of hand washing (as one of the least successful
ODF criteria); further investigating health as a motivator for behaviour; increasing systematic post-ODF
support (technical and motivational); strengthening community level processes and leadership; providing
access to finance (e.g., savings and loans, credit, etc.); and linking CLTS with sanitation marketing to
improve the technical quality of latrines and enhanced durability.
4.3 IDS SUSTAINABILITY AND CLTS

Factors contributing to CLTS sustainability are also set out in Cavill, Chambers, and Vernon (2015). Four
major sustainability studies are examined: Plan International research on ODF sustainability in Ethiopia,
Kenya, Sierra Leone and Uganda; UNICEF CATS Evaluation; WSP commissioned research on CLTS and
ODF sustainability in Indonesia; WSP study on CLTS and non-CLTS sustainability in Bangladesh. Other
sources included research by WaterAid, GOAL, and WSPs health outcomes.
Three dimensions are examined: enabling conditions (institutions, policy, etc.); physical and technical
sustainability (physical conditions, structures, markets, sanitation ladder); social and behavioural
sustainability (behavioural norms and dynamics within communities and cultures).
The findings for the enabling conditions were that sustainability improved when sanitation was a strong
political priority, e.g., through sanitation as a national policy, national sanitation campaigns with strong
political and administrative leadership at national and local levels, and multi-sector and multi-stakeholder
approaches. The quality of CLTS processes is fundamental for sustainable outcomes. Adequate
pre-triggering preparation and successful triggering are basic requirements, but added to this is
maximizing attendance to be inclusive of all community members including women (80 per cent of the
community present is needed as a rule of thumb). However this triggering also needs to be followed up
with regular visits after triggering and after ODF, and natural leaders, NGOs, local government and other
champions taking an active role in supporting the process.
The timing and phasing of marketing and sanitation services, microfinance and post ODF programming,
can help sustain CLTS, but so can the timely verification of ODF status so that a community gets quick
reinforcement of this new social norm.
Post ODF certification follow-up can help create long term sustainability, but sufficient budgets are
needed for NGOs and other implementers to do follow up support, re-verification, provide formalized
support to natural leaders and for continued visits by local governments. Post ODF support also includes
marketing and supply of materials. In Bangladesh, research recommended follow up village visits at least
once per month during the first year after verification.
Access to a range of financing mechanisms can help households get a toilet they want and improve
user satisfaction and physical sustainability. Sources may come from a households own savings, loans
from village savings groups and micro-credit, remittances, and sometimes targeted subsidies to replace
or upgrade basic toilets, for operation and maintenance (O&M), or to move away from shared toilets
to a household having its own toilet. Households do need to be regularly encouraged to move up the
sanitation ladder and, in Bangladesh, promotion was through a follow-up programme, a local government
champion, and support for entrepreneurs.
To improve physical and technical sustainability, areas affected by natural disasters (cyclones, floods,
tidal surges, monsoon rains, landslides or tornados) require appropriate technical designs and often,
post-disaster interventions. For the mainstream market, toilet quality, access to technical support
and market supply with products which meet the needs of low-income households (including for pit
emptying) will result in toilets which are more likely to last and be maintained.
Examples of social and behavioural sustainability include changing social norms, for example, public
pledging (West Bengal) for the community to commit to open defecation. Consistent and coherent
government cleanliness and sanitation promotion can encourage communities to change behaviour, for
example, community promotion which was reinforced by improvements in sanitation in schools and
anganwadis (nurseries for small children) in Madhya Pradesh, India, was successful.

Finding the right motivation for individuals and communities to give up open defecation and use
sanitation is important, with positive motivators being more effective than negative ones. The WSP study
in Bangladesh (Hanchett et al. 2011) found that persuasion, social norms, public education and community
level monitoring were more effective ways to motivate sustained ODF communities than threats,
coercion, fear and force. The Plan study (Tyndale-Biscoe et al. 2013) found the common motivators to be
health; shame/pride/disgust; privacy/security and convenience/comfort. Disgust is also a motivational
factor (Curtis 2013). These factors depend on geographic and religious characteristics and evolve over
time. Marriage in South Asia is closely related to norms and family status and can be a motivational factor
for the adoption of ODF behaviour: there are reports of households putting in a latrine to arrange a good
match for their child (e.g., Hanchett et al. 2011).
Natural leaders, chiefs or other respected local persons that perform home visits and door-to-door
monitoring to encourage people to maintain and improve on the new behaviours, conditions and facilities
that impact sustainability. The role of teachers at influencing behaviour and the part played by children
as natural leaders is also important. However the key is to include these key influencers throughout the
CLTS process. Very rarely are natural leaders formalized, however in Oromia, Ethiopia, natural leaders
have organized themselves into an association that is set up like a business, has legal status and its own
bylaws. The association focuses on ODF sustainability and moving communities up the sanitation ladder.
Shared toilets (public toilets) have a low impact on sustaining ODF behaviour change as they are prone to
uncleanliness, attract instances for violence and may drive people to continue open defecation practices.
Sustainability is increased if the CLTS process integrates equity and inclusion dimensions (particular
needs for access to sanitation for people with disabilities, elderly, chronically sick, low income community
members).
Sanctions against those who continue open defecation play an important part in social sustainability.
Sanctions may be community generated (e.g., whistle blowing or singing to open defecators, or deciding
community fines, e.g., refusing licences for those without toilets, withholding and delaying entitlement
payments, etc.).
The Institute for Development Studies (IDS) study concluded that the changes in behaviour and thinking
required to firmly accept and embed ODF and hygienic practices as social norms requires time, patience
and determination.
4.4 SANITATION AND STUNTING

Key findings have recently emerged from studies on the linkages between sanitation and stunting.
Stunting is a critical child development issue because it permanently affects cognitive development
and educational development of children (in turn affecting productivity in adulthood) as well as making
children more susceptible to diarrhoea, pneumonia, measles and other infectious diseases that can cause
death. In adulthood, women of shorter stature (due to stunting) have a greater risk for complications
during childbirth due to their smaller pelvis, and are at risk of delivering a baby with a low birth weight.
Stunted growth can even be passed on to the next generation through the intergenerational cycle of
malnutrition.
The effect of diarrhoea on malnutrition and stunting is well documented. However the wider effects
of all fecally transmitted infections on undernourishment and the case for sanitation and hygiene
remains a blind spot according to Chambers and Medeazza (2014). Recent studies highlight the effect
of environmental enteropathy when the absence of sanitation facilities and the exposure to fecal
contamination by children leads to frequent intestinal infections and causes the inadequate absorption of
nutrients leading to children becoming undernourished and stunted.
The effect of sanitation on stunting is documented by Spears (2013). Based on 140 Demographic and
Health Surveys, his research has found that open defecation accounts for much of the excess stunting
in India. He has shown that open defecation is even more harmful where the population density is high,
presenting conditions in which children (and adults) are more likely to be exposed to infections from
faeces. The relationship between open defecation and stunting is further confirmed for 112 districts of
India (Spears, Ghosh Cumming 2013). The researchers found that a 10 per cent increase in open

defecation was associated with a 0.7 per cent increase in both stunting and severe stunting.
Furthermore, Indian research found that having a toilet was not enough to change behaviour and that
many households still practiced open defecation despite having a latrine.
Research by Quattri and Smets (2014) using Multiple Indicator Cluster Surveys (MICS) data for rural Lao
PDR and Viet Nam found that community-level unimproved sanitation led to stunting in rural villages
regardless of if the childs household uses an improved toilet. Controlling the data for all factors that
may impact a childs height, the use of unimproved latrines in rural villages in mountainous regions of
Viet Nam led to five-year-old children being 3.7 cm shorter than healthy children living in villages where
everybody practiced improved sanitation. Children living in rural villages of Lao PDR, where community
members defecate in the open and/or use unimproved latrines, were 1.1 cm shorter than healthy children
living in rural villages where everybody used improved sanitation.
The study of the relationship between community level improved sanitation and stunting in rural poor
communities, concluded that:
Unimproved sanitation in rural villages leads to shorter children in those villages, even when
controlling for other socio-economic, demographic, health and environmental factors.
Neighbours poor sanitation negatively affects a childs height even when their own family uses
improved sanitation.
Local area poor sanitation causes children to be shorter at every age and permanently affects the
height of children.
The poorest segments of the population are suffering the most from a lack of improved sanitation.
The implications are that more policy and programmatic focus should be on community-wide (rather than
household) behaviour change and include targeted support for the poor. For CLTS, this increases the
importance of achieving 100 per cent ODF communities, in particular the importance of everyone having
sanitation that is improved.
An impact evaluation of CLTS in several thousand households in rural Mali (2014) found evidence that
the CLTS programme had a positive and significant impact on growth outcomes among children less
than five years of age. The findings suggest CLTS improved child growth and reduced child mortality
due to diarrhoea. However, the programme did not have a significant impact on self-reported diarrheal
illness, thus the programme may have impacted child growth and mortality through pathways other
than preventing diarrhoea, such as reducing the subclinical condition of environmental enteropathy via
decreased exposure to environmental fecal contamination.
At a more general level, there are correlations between the countries around the world which have
the highest numbers of open defecators, the highest numbers of under five deaths and the largest
proportions of stunted children: out of the 20 countries with the most open defecators, 17 have stunting
rates of 35 per cent or higher (WHO and UNICEF 2012; UNICEF 2012). This trends generally bears out
for rural sanitation in the East Asia Pacific region, with Cambodia, Lao PDR, Indonesia, Timor-Leste
and Solomon Islands having both high rates of open defecation and stunting above 33 per cent. The
exceptions are Papua New Guinea with open defecation only at 13 per cent (but unimproved sanitation
at 87 per cent) and stunting at 44 per cent; while Myanmar has 6 per cent open defecation but a stunting
rate of 35 per cent.
Taking this recent research into account, CLTS still remains a valid and relevant tool for addressing open
defecation with the following attributes at its core:
Triggering through disgust, convenience and other motivators to mobilize individuals to change their
behaviour to use a toilet.
Producing a collective result, whereby whole communities end open defecation and in some cases
improve their sanitation standards.

5FINDINGS
PART I 5Findings
The review covered 14 countries in the East Asia and Pacific region.
EAST ASIA SOUTH-EAST ASIA PACIFIC

1 China 4 Cambodia 11 Kiribati
2 DPR Korea 5 Indonesia 12 Papua New Guinea
3 Mongolia 6 Lao PDR 13 Solomon Islands
7 Myanmar 14 Vanuatu
8 The Philippines
9 Timor-Leste
10 Viet Nam
The findings are presented in the sections that follow, starting with a comparative analysis of country
context and CLTS achievements and progress; presentation of the country scorecards on factors for CLTS
success; and then discussion on some of the other key CLTS practice issues.
5.1 COUNTRY CONTEXTS

The review highlighted the significantly different contexts and sanitation situations found across the
region. Table 5.1 summarizes some key development indicators: with populations ranging from 100,000
people to 1.37 billion; GNI per capita from US$ 880 to US$ 5,740; the proportion below the international
poverty line (US$ 1.25 per day) from 12 to 34 per cent; and stunting rates from 10 to 58 per cent.
Country GNI per capita and populations have risen since the 2012 CLTS review report, however the data
shows little change in stunting rates.
Table 5.1 Key development indicators (ranked by subregion and population)

POPULATION GNI PER CAPITA POVERTY STUNTING
COUNTRY (2012) US$ (2012) (% BELOW US$ 1.25) (%)6
East Asia
China 1,377.0 million US$ 5,740 12% 10%
DPR Korea 24.8 million 28%
Mongolia 2.8 million US$ 3,160 15%
South-East Asia
Cambodia 14.9 million US$ 880 19% 40%
Indonesia 246.9 million US$ 3,420 16% 44%
Lao PDR 6.6 million US$ 1,260 34% 48%
Myanmar 52.8 million 35%
The Philippines 96.7 million US$ 2,470 18% 32%
Timor-Leste 1.1 million US$ 3,670 58%
Viet Nam 90.8 million US$ 1,400 17% 23%
Pacific
Kiribati 0.1 million US$ 2,260
Papua New Guinea 7.2 million US$ 1,790 44%
Solomon Islands 0.5 million US$ 1,130 33%
Vanuatu 0.2 million US$ 3,080 26%
Total 1,922.4 million
Source: UNICEF online country statistics (accessed September 2015)
6 Moderate and severe (latest data available from www.childinfo.org).

Figure 5.1 Rural population sanitation access by open defecation rate (per cent)
PART I 5Findings
Solomon lsland 66 19 0 15 Open defecation
Cambodia 60 3 7 30 Unimproved sanitation

Kiribati 49 17 3 31 facilities
Shared sanitation
Lao PDR 37 5 2 56 facilities
Timor-Leste 36 31 6 27 Improved sanitation
Indonesia 29 12 12 47
Mongolia 27 0 30 43
Papua New Guinea 13 71 3 13
The Philippines 10 1 18 71
Myanmar 6 6 11 77
Chaina 2 31 3 64
Vanuatu 2 28 15 56
Viet Nam 1 25 4 70
DPR Korea 0 24 3 73
0 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Source: JMP progress report, 2015.
There are also dramatic variations in the sanitation situation in the 14 review countries, with rural open
defecation rates varying from 0 to 66 per cent:
less than 10 per cent open defecation in DPR Korea, China, Vanuatu, Viet Nam and Myanmar;
10-30 per cent open defecation in the Philippines, Papua New Guinea, Mongolia and Indonesia;
30-50 per cent open defecation in Timor-Leste, Lao PDR and Kiribati; and
60 per cent and over open defecation in Solomon Islands and Cambodia.
In total, the 14 review countries contain a rural population of 65 million people practicing open defecation
in 16 million households. This is a reduction in people practising open defecation by 71 million people
since 2000 (and 5 million people since 2012), contributed mainly by China, Indonesia and Viet Nam. As
with the situation in 2012, most of the open defecation population continues to be concentrated in three
of the review countries:
Indonesia: 34.3 million open defecation rural population (54 per cent of regional total)
China: 12.4 million open defecation rural population (15 per cent of regional total)
Cambodia: 7.4 million open defecation rural population (12 per cent regional total)
Figure 5.1 also illustrates some variations in the proportions of the rural population using unimproved
sanitation facilities:
> 70 per cent unimproved sanitation coverage = 1 country (Papua New Guinea)
12-31 per cent unimproved sanitation coverage = 8 countries (Timor-Leste, China, Vanuatu, Viet Nam,
DPR Korea, Solomon Islands, Kiribati and Indonesia)
< 10 per cent unimproved sanitation coverage = (Cambodia, Lao PDR, the Philippines and Myanmar).
Sharing of sanitation is high some countries, e.g., 30 per cent in Mongolia.

5.2 COUNTRY CLTS OVERVIEWS
PART I 5Findings
5.2.1 Maturity of CLTS

CLTS was first introduced into the region in 2004, reaching 12 of the 14 countries by 2015, as illustrated
in the timeline figure below. As with the 2012 review, DPR Korea and Vanuatu remain the only two
countries examined by the review where CLTS had not been introduced. Vanuatu is unlikely to introduce
CLTS as it has very little open defecation and the focus will be on shifting people from unimproved to
improved sanitation. Similarly, DPR Korea also has low open defecation rates, but there is scope to
improve sanitation facilities and excreta management.
Figure 5.2Timeline: Date of introduction of CLTS

11 YEARS AGO 10 YEARS AGO 9 YEARS AGO 7 YEARS AGO 5 YEARS AGO 4 YEARS AGO 3 YEARS AGO
2004
2005
Cambodia 2006
2007
Indonesia
China-1 2008
Timor-Leste
Lao PDR 2009
The Philippines
2010
PNG
Viet Nam 2011
Myanmar 2012
Mongolia
China: CLTS reintroduced Kiribati
Solomon
Islands
China-2
The 2012 review identified Cambodia and Indonesia as Early adopters, Timor-Leste, Lao PDR, the
Philippines, Papua New Guinea and Viet Nam as Mid-term adopters, and Myanmar, Mongolia, Kiribati,
Solomon Islands and China as Late adopters. The results from the latest review suggest that progress
is not so dependent on when a country adopts CLTS but on how comprehensive its approach is, and that
progress towards scaling up may be more sporadic than linear.
5.2.2 Geographical spread

The review also re-examined the extent to which CLTS has spread within the countries reviewed.
This indicator measures the number of provinces or districts (if this is the largest geographical unit,
e.g., Timor-Leste) to which CLTS implementation had been introduced the assumption being that
geographical targeting often constrains programme spread to specific provinces.7
Whereas the 2012 review found that CLTS has spread furthest in the early and mid-term adopting
countries, current information shows that the countries to most recently adopt CLTS have made
significant progress at spreading CLTS (Mongolia, Kiribati, Solomon Islands, and to some extent
Myanmar). One conclusion for this trend is that late adopting countries have the benefit of lessons
learned from other countries and can roll out CLTS more effectively. This may explain some of the
progress but would mean that an increase in spread would also be expected from countries such as
the Philippines and Viet Nam, who have seven to eight years of experience and have acquired learning
in that time. This is not the case, hence the conclusion is that enabling environment factors such as
government leadership, policy and financing are constraining the spread in early adopting countries.
7 Some countries have increased the number of provinces, however this has had little impact on the data.

Figure 5.3 Geographical spread of CLTS implementation (per cent of provinces, 2012 and 2015)
PART I 5Findings
120
Indonesia Timor-Leste Papua

New Guinea
100
Cambodia
80
Lao PDR
60
Kiribati Solomon
Islands
40 Viet Nam Myanmar

Mongolia
The Philippines
China
20
0
2004 2005 2007 2007 2008 2008 2008 2010 2011 2011 2012 2012
Geographical spread 2015 Geographical spread 2012
In the Philippines and Viet Nam, CLTS is not yet part of a major government programme and CLTS
interventions are currently concentrated in a few provinces, although this is likely to change in the
future. The expansion of CLTS in Cambodia is due to major funding through the Global Sanitation Fund
Cambodia Rural Sanitation and Hygiene Improvement Program (CR-SHIP) 2012-2015) and UNICEFs
WASH Programme implemented by the Ministry of Rural Development, through Provincial Departments
of Rural Development in 11 provinces.
The reasons behind geographical programme targeting vary by country and programme, but most
sanitation programmes aim to target areas with high rates of open defecation and areas where
sub-national governments show demand and commitment to sanitation improvement.
In Cambodia, the national CLTS guidelines provide criteria for village selection based on low sanitation
coverage, village accessibility, absence of other programmes, commitment by local authorities and
participation by villagers. Some implementers have more specific criteria including: population density,
poverty rates, health-related data for children under five years, current or planned water sanitation and
hygiene activities by development organizations and NGOs, as well as commitment and capacity of local
authorities. SNVs district wide approach results in the selection of districts being made in consultation
with the Ministry of Rural Development and provincial partners.
In Myanmar, the choice of location is based on low sanitation coverage and high diarrhoea incidence
areas, and additionally for UNICEF, targeting of poor nutrition and poor health access areas that integrate
with its health and nutrition programmes.
In the Philippines, UNICEF areas are selected based on the country programme targeting of areas
vulnerable to disaster and conflict. In Typhoon Haiyan-affected areas, 40 priority local government
units (LGUs) were identified based on a multi-risk assessment done by UNICEF and the government.
Other programmes, such as the Scaling Up Rural Sanitation Programme, target poor communities in
areas with low sanitation coverage and high open defecation, with health and nutrition added by some
implementers. The NGO Action Contra Le Faime (ACF) selects locations using all these criteria, as well as
targeting the most vulnerable barangays with high concentrations of indigenous people.
In Viet Nam, priority is given to areas with high open defecation rates, ethnic minority groups, and remote
and mountainous areas. At village level, pilot villages tend to be populous with large numbers of children,
low rates of latrine coverage, and many poor households.

In Timor-Leste, the focus has been on areas with low sanitation coverage and high malnutrition status
PART I 5Findings
according to the Demographic Household Survey 2009-2010. The Ministry of Health (MoH) works with
programme implementers to select locations.
In Lao PDR, locations have been selected based on high rates of open defecation and undernutrition,
high rates of diarrhoea, and poverty. One exception is Borikhamxay province, it was chosen by the
government due to its proximity to the capital as a means of strengthening national capacity for
demand-based approaches to sanitation.
In Indonesia, according to national policy, CLTS should be implemented in all communities as the main
requirement for achieving ODF status and low access to sanitation is prioritized when selecting districts.
For Papua New Guinea, CLTS is implemented within the catchment areas of local NGOs, international
non-governmental organizations (INGOs) and community-based organizations (CBOs), usually as part of
WASH components within integrated development programmes. CLTS is therefore implemented on a
very location-specific basis.
5.2.3 Institutional coverage

Data on the institutional coverage of CLTS, i.e. the number and type of sector organizations that were
known to be actively promoting or implementing CLTS, shows that the number of organizations is less
important than the quality and influence of organizations. Several countries such as Indonesia and
Timor-Leste have seen the number of organizations involved in CLTS consolidated. This tends to
happen as funding opportunities change, particularly for NGOs who move out of WASH and into other
programme areas. The opposite is also true when new funding is available. In the Philippines, the
development of a Phased Approach to Total Sanitation (PhATS), under the WASH Cluster strategy in
response to Typhoon Haiyan, has led to an increase in the number of international NGOs implementing
CLTS, including through the adoption of the approach by traditional humanitarian NGOs. The number of
organizations has increased in Cambodia as a result of funding from the Global Sanitation Fund.
A new development is the participation of the private sector in both Indonesia and Lao PDR, where a
mining company and a hydropower company respectively have actively promoted CLTS in operational
areas. Although location specific, there would seem to be opportunities for private sector involvement
in the future, especially as part of corporate social responsibility.
Other institutional variants of CLTS include the integration of CLTS in the Philippines Department of
Social Welfare and Development (DSWD) Pantawid Program (refer to the case study).
5.2.4 CLTS scale

CLTS scale was measured by collating data on the number of communities where CLTS had been
used to trigger sanitation improvement; and on the number of ODF communities. These indicators
provide some measure of the scale of CLTS implementation in each country, and the scale of improved
outcomes.
Few countries in the region have operational systems to verify ODF status or check whether ODF
outcomes are sustained. Therefore, the data presented below are the number of ODF communities
reported by the country review teams, based largely on information that they received from
implementing agencies. These data include a mixture of self-declared ODF communities, and ODF
communities certified by the implementing agencies or local governments. Very few sustainability
checks have been carried out, therefore these data may include some communities that were
self-declared ODF but have not fully met ODF criteria, and other communities that were genuinely
ODF at declaration, but in which some households have since reverted to open defecation.

PART I 5Findings
18
Figure 5.4 CLTS progress (number of triggered and ODF communities in 2012 and 2015, by year of introduction)
24955
8000
7325
7000
6106
6000
5000
419
4000
3000
2025
2000
1502 494
27
761 1000 666
677 829
1000 608 602 565
473 477 171 531
211 262 217 144 224 135
144 145
36 36 21 12 63 0 0 50 31 10 0 10 0 0 0 103 2 0 50 0
0
Cambodia Indonesia The Philippines Timor-Leste Lao PDR Papua Viet Nam Myanmar China Mongolia Kiribati Solomon
New Guinea Islands
Triggered communities 2012 ODF communities 2012 Triggered communities 2015 ODF communities 2015
East Asia and Pacific Regional Report
Figure 5.4 charts the scale of CLTS activities by country for 2012 and 2015, in terms of the number of
PART I 5Findings
triggered and ODF communities, with the order determined by the year of CLTS introduction. The figures
are cumulative.8 This chart highlights the overall increase in triggering for every country, and an
exponential increase in some countries. A significant increase in triggering has occurred between 2012
and 2015 in Viet Nam (240 per cent), Indonesia (340 per cent), and Cambodia (400 per cent).
The proportional increase in ODF communities over that period is similar for Viet Nam (320 per cent),
and Indonesia (340 per cent), but the data was incomplete for Cambodia. While the increase in
percentage terms of triggering and ODF communities is similar over time, the actual numbers of
triggered communities suggests a huge requirement for ODF certification. In the case of Indonesia this
means there are more than 20,000 triggered communities to be verified and certified, and at least 4,000
in Cambodia.
5.2.5 ODF success rate

The ODF success rate, defined as the proportion of triggered communities that become ODF, is a key
indicator of the effectiveness of CLTS implementation. The ODF success rate does not tell us anything
about the quality or sustainability of collective sanitation outcomes, but it is a key indicator of CLTS
effectiveness that can highlight problems as programmes spread and scale up, and can be used to
compare country performance. The data weakness is that some of the communities are self-declared
without independent verification.
Data from 2012 and 2015 is aggregated at the country level. Most CLTS reviews find substantial
variations in the ODF success rate across both large and small programmes, and even under the same
conditions within the same programme. In the case where there are successful programmes or pockets
of high effectiveness, these are averaged across the countrywide information.
The success rates for 2012 and 2015 are plotted in Figure 5.4. In 2012, the success rate was higher in
those countries that adopted CLTS earlier. In 2015, this was not the case. While country success has
increased for all countries (except Cambodia) between 2012 and 2015, the countries recently introducing
CLTS have also achieved success. It could be that these more recent countries have had the benefit of
experience from the early adopters and have been able to leap frog in progress.
The data shows reduced effectiveness for Cambodia and stagnated success at converting triggered
communities to ODF for Indonesia. This could be because these early countries have not adapted as
quickly as others, but regardless, this is a concern for Indonesia, because of the many thousands of
communities that have been triggered to date.9 The Philippines has achieved a high ODF success rate
(70 per cent), largely due to the results from triggering and ODF achievement in Typhoon Haiyan-affected
areas where the success rate is 84 per cent. The reasons for high and swift ODF achievement in
Haiyan-affected areas are the development of sanitation action plans at community level and a focus on
local government service delivery, combined with intense investment and support from implementers
to achieve this result. By comparison, UNICEFs normal development activities in the Philippines had a
success rate of 29 per cent and WSP at a 54 per cent success rate.
A drawback in the success ratio is that this indicator conceals progress towards increased sanitation
coverage and reduction in open defecation, but without reaching 100 per cent. An example from
Timor-Leste highlights this point in some UNICEF sites, open defecation has reduced from a baseline of
71 per cent in 2011 to an endline of 4 per cent in 2014. Across the AIieu district in Timor-Leste, sanitation
coverage was barely 20 per cent in 2009, but by 2015 it was estimated to be 85 per cent, even taking
slippage into account. This represents a significant change in uptake of sanitation and ceasing open
defecation that is not captured in the data. The situation is believed to be similar for other countries,
(although not specifically documented) and highlights the importance of follow-up interventions in
project communities that do not achieve ODF status following CLTS interventions, in order to reach the
remaining 10-20 per cent of households.
8 The bar for Indonesia is truncated due to scale.

9 Data issues for Cambodia may also explain the apparent backslide in success.

Figure 5.5 ODF success rate for 2012 and 2015 (percentage, by year of CLTS introduction)
PART I 5Findings
Kiribati
80
The Philippines
70
China
Timor-Leste
60
50
Cambodia
40
Lao PDR Viet Nam

30
Papua
Indonesia New Guinea
20
Myanmar
10
Solomon
Mongolia Islands
0
2004 2005 2007 2007 2008 2008 2008 2010 2011 2011 2012 2012
CLTS success rate 2015 CLTS success rate 2012
5.2.6 Successful triggers

Effective triggers vary between countries, although disgust is universal. Several countries found that
shame was ineffective and that a more positive approach was needed, otherwise communities could
be alienated from CLTS altogether. Desire for good health and the stigma of continuing open defecation
practices while others in the community ceased the practice were consistently mentioned as triggers.
The different types of triggers mentioned by countries is shown in Figure 5.6.
Involving children in triggering is effective, as parents find it difficult to resist if their child asks them
to stop openly defecating and acquire a toilet. Related to this is that parents are strongly motivated by
the desire to protect the health of their children. In the Philippines, post-triggering hygiene promotion
sessions among children, in the form of creative activities such as singing, dancing, theatre, film
showing, etc. has a strong impact on parents and other adults in the community. In Cambodia, triggering
children results in children pleading to their parents to build a toilet for them.
Collective village benefits, new social norms, village pride and competition between villages become
important when leaders have an interest in improving sanitation and can influence the situation. In Timor-
Leste triggering around social norms and reaching sanitation standards has become important to mobilize
village and community leaders to achieve the Bobonaro District Administrators goal that the district
become ODF by 2016.
In the Philippines, effective triggering strategies include: calculation of faeces and the amount spent on
medical expenses, transect walk, glass of water demonstration, and food and faeces demonstration.
In Papua New Guinea, community mapping and the transect walk generates shame and disgust.

Figure 5.6 Word cloud of effective triggers
PART I 5Findings
5.3 CLTS SCORECARD

The following sections summarize the review findings on the CLTS scorecard for each country. The
scorecard covers the enabling environment, implementation and sustainability, and monitoring and
evaluation.10 The table below summarizes the scorecard by indicator for national level implementation.
This assessment was made based on the actual situation for mid-2015, with planned developments
described in the text of individual country reports but not counted in the assessment.
The red sections in the table below (Table 5.2) highlight gaps and the large amount of work still required
to strengthen and improve CLTS enabling environments, processes and systems across the region.
5.3.1 CLTS in government policy

The country CLTS overviews suggest that a government sanitation policy is an important factor in
the scaling up and effectiveness of CLTS programmes, as it is the first step in the official government
endorsement of the CLTS approach. In 2012, only three countries had government policies that
recognized and promoted the principles of the CLTS approach Cambodia, Indonesia and Timor-Leste.
The number is now up to eight out of the 12 CLTS implementing countries, indicating a significant shift
in acceptance of CLTS and movement away from heavily subsidized programmes.
Several country policies do allow subsidies, but only when targeted to the poor, disadvantaged, and in
technically challenging environments (Cambodia, Timor-Leste, Papua New Guinea and Solomon Islands).
10 Thescorecard concept was developed based on the UNICEF WASH Bottleneck Analysis Tool and the World Bank WSP Service Delivery Assessment
scorecard.

PART I 5Findings
22
Table 5.2 Summary of CLTS scorecards

Papua New The Solomon Timor-
Cambodia China DPR Korea Indonesia Kiribati Lao PDR Mongolia Myanmar Vanuatu Viet Nam
Guinea Philippines Islands Leste
ENABLING
Policy CLTS in government policy
ENVIRONMENT
CLTS targets in
Strategy government strategies
or development plans
Leadership CLTS led by government
CLTS financed by
Finance
government
Mechanisms for
Coordination
stakeholder coordination
IMPLEMENTATION
CLTS integrated with
AND Integration
other approaches
SUSTAINABILITY
Standardized Facilitator
training
Triggering
Facilitator quality
control
Clear ODF criteria
ODF Verification protocol
Post ODF support
Technical Availability of products

Support and services
MONITORING Robust and regular

AND monitoring of ODF
EVALUATION achievements
Monitoring
Post ODF Monitoring of

quality and sustainability
Evaluations, reviews
Evaluations
and learning
and
knowledge
Information on costs
sharing
and resources for CLTS
Key: red = little or no evidence of the criteria met, or the policies, tools and systems are not in place;
yellow = criteria partially met, there is some movement towards achieving the criteria e.g. draft/planned/maybe; or
green = criteria is met and systems tool, policies etc. are formalized and in use.
Table 5.3 Sanitation policies by country
PART I 5Findings
COUNTRY RURAL SANITATION POLICY
FORMAL POLICY
Indonesia The 2008 National Strategy for Community-Led Total Sanitation (STBM strategy) in Indonesia provided
a definition for an improved latrine an effective sanitary facility to break the transmission of disease
and stated that subsidies should not be provided for household sanitary facilities.
Cambodia The 2013 National Strategy for Rural Water Supply, Sanitation and Hygiene (RWSSH) 2011-2025 states
use of sanitation behaviour change approaches (e.g. CLTS) and the promotion of local markets to deliver
sanitation products and services so that households buy, construct and use latrines. Public finance
should mainly be used to stimulate demand and develop the enabling environment. Direct hardware
subsidies can only be used in a targeted manner to support the poor.
Timor-Leste 2012 National Basic Sanitation Policy the first of four main objectives of the policy is for the
achievement of an open defecation free environment; with households responsible for the
construction and maintenance of their own sanitation facilities, including a hygienic toilet and
handwashing facility. The policy allows for household sanitation facilities to be subsidized only where
households are disadvantaged.
Lao PDR 2014 MOH Operational Program Guideline provided a systematic framework for the planning,
implementation, monitoring and evaluation of rural sanitation programmes under the umbrella of the
2012 National Plan of Action for Rural Water Supply, Sanitation and Hygiene. The demand creation and
behaviour change approach is through CLTS.
Papua New Guinea The 2015 National WASH Policy aims for 100 per cent total sanitation; with a focus on changing
behaviour through the promotion of safe sanitation facilities, leading to zero open defecation. Subsidies
for sanitation should be limited but can be considered if carefully targeted to promote access for
the poorest and disabled, improved menstrual hygiene, innovation, and sanitation in challenging
environments.
The Philippines The Department of Health Administrative Order 2010-0021 Declaring National Sustainable Sanitation as a
National Policy defines sustainable sanitation as achieving ODF communities. CLTS is the major pillar of
sustainable sanitation programme development.
Solomon Islands The 2014 National RWASH Policy identifies CLTS as one participatory approach that can be used to
improve sanitation coverage. The policys vision is for all Solomon Islanders to have easy access to
appropriate sanitation, as delivered through participatory zero-subsidy approaches. Subsidies will still
be considered where the only environmentally appropriate technical solution falls outside the financial
means of the average household, education facilities and health facilities.
Viet Nam Rural Water Supply and Sanitation National Target Program III Phase 2012-2015 Decision 366 describes
toilets as a household responsibility. The programme focus is on sanitation targets, particularly
household latrines with priority to low-cost models and preferential credit to improve the access of the
poor, and behaviour change sanitation promotion. The MoH 2013 National Guideline for Planning and
Implementation on Rural Sanitation includes creation of collective demand for rural sanitation, using
community approaches such as CLTS.
NON-SUPPORTIVE POLICY FRAMEWORK
China Collective sanitation is set as a principle in the sanitation authoritys (NPHCCO) policy on the rural
sanitation movement. It requests whole village improvement but does not specify CLTS. 2003 technical
standards require leak-proof latrine pits and tanks, and National Patriotic Health Campaign Committee
promotes relatively expensive standard designs, which limits the role of CLTS. In 2009, the central
government listed Rebuilding sanitary toilets in rural areas as one of six national important public
health services programmes, however sanitation subsidy is acceptable.
Kiribati 2010 National Sanitation Policy. General policy that promotes enhanced community awareness of
sanitation and public health and hygiene requirements but does not contain any specific references to
programme methodologies or detailed technical requirements.
Mongolia 1998 Law of Mongolia on Sanitation. Sanitation defined as activities to eliminate the adverse natural
and social factors having potential impact on public health, and to prevent the public health from
diseases. Normal sanitary conditions: a healthy and safe environment for a human to work and to live.
Vanuatu The MoHs National Environmental Health Policy and Strategy 2012-2016 includes water, hygiene and
sanitation as one of its core health prevention strategies, specifically aimed at MDG7 for increasing
access to improved sanitation. The strategy has a goal of 80 per cent of the rural population having
access to improved sanitation by 2016. The strategy to achieve this is by developing national sanitation
standards for toilets, and improving sanitation facilities in communities, schools and health facilities.
DPR Korea Government building codes define construction standards in rural areas. The sanitary double pit latrine
was selected for demonstration and adaptation to the DPRK context as the highest standard for rural
sanitation.
NO SANITATION POLICY
Myanmar No national sanitation policy

5.3.2 CLTS in government plans and strategies
PART I 5Findings
A number of countries have sanitation targets and sanitation strategies but only Indonesia, the
Philippines, and Solomon Islands have strategies with clear ODF targets. Cambodia is currently
developing a National Action Plan which will set out annual ODF targets, while Timor-Leste is currently
reviewing the 2012 draft National Strategic Sanitation Plan which will plan and cost how to achieve the
countries broader sanitation targets.
Table 5.4 Rural sanitation strategies and plans

COUNTRY RURAL SANITATION STRATEGIES AND PLANS
Indonesia 2010-2014 National Mid-Term Development Plan (RPJM-N) sets the target of 100 per cent ODF villages
nationally by 2014. The new RPJMN-3 2015-2019 has the goal of universal access by 2019, however the
interpretation of this is unclear.
Solomon Islands National Rural WASH strategy has targets for nationwide sanitation coverage by 2024. 100 per cent
ODF status is required.
The Philippines 2011 National Sustainable Sanitation Plan of the Department of Health aims for 60 per cent Zero Open
Defecation (ZOD) barangays by 2016 and 100 per cent ODF by 2022.
Viet Nam 85 per cent of hygienic toilets by 2020, with the draft five year sanitation plan 2016-2020 including
annual targets and roadmaps for ODF by 2025.
Cambodia 100 per cent of sanitation coverage by 2025, but no ODF targets in national strategy for RWSSH. A
new National Action Plan (under development) will include specific indicators and targets for ODF.
Lao PDR The government does not currently have a target for achieving ODF but has set a target for achieving
80 per cent sanitation coverage by 2020.
Kiribati National Sanitation Implementation Plan, but no specific ODF targets. The President has called for an
ODF Kiribati by 2015.
China 12th Five Year Plan aims to have a 75 per cent sanitary latrine coverage in rural areas by 2015.
Timor-Leste No sanitation strategy. Draft National Strategic Sanitation Plan developed in 2012 is being revised.
Papua New Guinea No sanitation strategy.
Myanmar No sanitation strategy.
As found in the 2012 review, the operationalization of national level targets through strategies and plans is
poor. Many national targets are ambitious, and where sanitation strategies and plans appear supportive,
there is little evidence that these planning frameworks translate into larger scale or more effective
programmes or outcomes.
For example, Indonesia has already fallen short of its 2014 ODF target of 100 per cent, with only 4,500
villages out of 80,000 (5.6 per cent) certified as ODF. Similarly, the Philippines aims for 60 per cent of
barangays to be ODF by 2016, but currently only 470 out of 42,000 (1.1 per cent) have achieved this.
The 2012 review suggested that there was a significant disconnect between national sanitation targets,
sanitation strategies and plans (where they exist), sector investments and implementation programming,
with few national sanitation strategies or plans that appear to be based on realistic, costed assessments
of how targets will be reached, or any attempt to map out the strategic priorities en route to these
targets. There appears to be no change to this situation in 2015 and sanitation planning remains weak.
Countries that are developing detailed plans (Cambodia and Timor-Leste) may provide guidance for other
countries to follow.

5.3.3Leadership
PART I 5Findings
The highest level of government involvement in leadership of CLTS is found in Indonesia, the Philippines
and Kiribati.
Indonesia: CLTS (STBM) is a government programme under the MoH, which sets policy and strategy.
Government is involved at central level, provincial and local level. Provincial and district governments are
active in some but not all areas.
The Philippines: At the central level, the Department of Health develops and implements policies,
and provides operational strategy for scaling up rural sanitation programme nationwide. DOH regional
coordinators are in charge of rolling out CLTS in their respective provinces. Government WASH taskforces
at provincial and municipal level are responsible for planning, monitoring and for allocating resources.
LGUs are actively involved in some areas.
Kiribati: CLTS is led by the Ministry of Public Works, and MoH and medical services, with a high level of
commitment from the President of Kiribati. Island Councils (Ministry of Internal Affairs) play a key role and
lead the process locally.
Viet Nam, Cambodia, Lao PDR, Timor-Leste, Solomon islands and China have some level of government
involvement in CLTS, usually at the central level and, in some of these countries, in selected districts.
In Papua New Guinea, Myanmar and Mongolia, the process is lead by NGOs or other implementers with
CLTS not implemented as a government programme under the leadership of government.
5.3.4 CLTS financed by government

Government financing for CLTS remains one of the weakest areas of the enabling environment in the
EAP region. Despite the growing acceptance of CLTS as an approach to sanitation (evidenced by its
inclusion in policies), commitment to financing CLTS remains low.
Four countries contribute direct finance: Indonesia invests directly in CLTS activities, through support to
STBM activities, and counterpart financing to the World Bank supported PAMSIMAS programmes. The
Philippines Department of Health allocates an average of Php 1 million (< US$ 22,000) every year at the
national level for the CLTS programme, which is used for capacity building and guidance. The Government
of Kiribati is providing complementary funding to support the EU-KIRIWATSAN-1 programme to extend
CLTS implementation to additional outer islands. In the Solomon Islands, the MoH and medical services
have allocated approximately 17 per cent of the Environmental Health Budget for CLTS. Of this,
41 per cent is for consultancy/staff, 23 per cent for transport, and the remainder for supplies.
In both Indonesia and the Philippines, subnational level governments are contributing funding to CLTS
implementation through annual investment planning processes, but this is typically for where there
has been substantial external advocacy, combined with capacity building support for annual planning
and budgeting.
In other countries where there is a sanitation budget, finance may be provided for CLTS but at a much
smaller scale or for specific purposes such as training and communication (Viet Nam), post triggering
follow-up, and ODF verification (Lao PDR). Both Cambodia and Lao PDR use the majority of their
sanitation budget for hardware subsidies.
Unsurprisingly, in countries where CLTS is outside the government system, e.g., Papua New Guinea,
Myanmar, Mongolia, and China, no government funding is provided to CLTS implementation. The stand
out exception is Timor-Leste, where there has been strong engagement with government, development
of a sanitation policy and a draft sanitation strategy, and hardware subsidies have been eliminated, but
this progress is yet to translate into a funding commitment from government. Development partners
continue to underwrite CLTS to a large extent.

5.3.5 CLTS coordination
PART I 5Findings
In most countries CLTS coordination occurs through WASH or sanitation working groups, where CLTS is
one of a number of topics discussed. Given the growing integration of CLTS into more complex sanitation
approaches, the need for standalone CLTS coordination events is questionable (except on specific
technical issues). More important is the need for: regular coordination meetings; depth of coordination
(different levels of government from the central to local); and government leadership of coordination.
Regular coordination is a feature in Indonesia, Lao PDR, Kiribati and the Philippines. In Indonesia, the
AMPL Pokja or WASH working group provides an important forum for the coordination of government
agencies and development partners, with a structure mirrored from the national level to province and
district level government, although the quality and consistency varies at subnational level. In Lao PDR,
a government led WASH Technical Working Group meets regularly and discusses sanitation issues
including CLTS and subsidies. In Kiribati, a core technical team of 73 people from the government and
NGOs regularly coordinate and lead CLTS.
In the Philippines, coordination is more prevalent at the subnational level, including through WASH
taskforces at the provincial, municipal, and barangay levels in locations where CLTS is being supported.
The Solomon Islands has both a government coordinated WASH Stakeholder Group that meets quarterly
and a national hygiene and sanitation technical group. In Viet Nam, coordination is less regular, occurring
through annual reviews.
In other countries (Papua New Guinea, Myanmar, Mongolia) coordination is ad hoc or non-existent, with
no formal mechanism.
5.3.6 CLTS integrated with other approaches

This review found a number of examples of integration of CLTS into other programmes and approaches.
However many of these country examples are on a small scale carried out by selected projects or
NGOS or are in the early stages of integration, such as much of the work around nutrition.
Table 5.5 Integration of CLTS

MOTHERS WASH
SANITATION HYGIENE/ EARLY WASH IN POVERTY SAFETY
COUNTRY MARKETING HWWS NUTRITION CHILDHOOD SCHOOLS REDUCTION PLANS
Cambodia u u u u
China u u u
Indonesia u u u
Kiribati u
Lao PDR u u u u u
Mongolia
Myanmar u u u u
Papua New u u
Guinea
The Philippines u u u u u
Solomon
Islands
Timor-Leste u u
Viet Nam u u u

Some examples of large scale or emerging integration include:11
PART I 5Findings
Cambodia combining sanitation demand creation, sanitation supply chain strengthening, hygiene
behavioural change communication, and WASH governance through SNVs Sustainable Sanitation and
Hygiene for All (SSH4A) initiative (sanitation marketing);
The Philippines CLTS triggering in Family Development Sessions for Department of Social Welfare
beneficiaries (poverty reduction); and
Cambodia several NGOs combine CLTS with nutrition interventions, and a new USAID NOURISH
program will integrate CLTS and nutrition at scale (nutrition).
5.3.7 CLTS triggering

It has long been confirmed that the quality of facilitators is one of the critical factors in delivering
effective triggering as a precursor to sustainable sanitation. This review considered the degree to which
there was consistency and quality of facilitator training, and whether training is institutionalized or even
professionalized, including the quality control of the triggering of facilitators. Across the 12 countries
implementing CLTS, there exists a full spectrum of facilitator quality. Even in those countries with
standardized training, on the job monitoring and follow-up receive the least attention.
At the advanced end of the spectrum, Indonesia has been institutionalizing facilitator skill development
since 2013 through the MoH with support from the World Bank, and its approach is somewhat of a model
for other countries to consider. Institutionalization of capacity building of STBM human resources has
three distinct target groups: (i) current STBM implementers (in-service); (ii) environmental health students
at health polytechnic schools who will be future sanitarians (pre-service); and (iii) those interested in
STBM and other members of the general public as a secondary audience. To reach these target groups,
three instruments were developed: (i) accredited training for STBM implementers; (ii) integrating STBM
into environmental health curriculums at health polytechnics; and (iii) e-learning for both groups and for
the general public (refer to Figure 5.7).
Health polytechnics were selected as training centres as this is where, since 2013, Government
sanitarians, who are key actors of STBM as implementers of environmental health programmes, must
graduate from. New graduates now automatically receive STBM training.
Distance learning aims to increase the outreach of learning opportunities and resolve geographical and
financial challenges around face-to-face training. Learning is in two stages: e-learning (online) focusing on
the concept of STBM or cognitive aspects, and conventional learning (offline) emphasizing STBM skills
such as triggering, marketing and monitoring. The e-learning module has to be completed before further
practical STBM training is undertaken. Trainees of e-learning receive a certificate of participation and
trainees who complete the off-line training receive a certificate of competence.
Indonesia has standardized and accredited its curricula and modules to not only improve the quality
of delivery but also to motivate trainees through formal recognition, as well as linking the completion
of training to the MoH incentive system for career development opportunities for civil servants and
enhanced training opportunities for non-civil servants.
For civil servants such as sanitarians, the training is recognized under existing civil servant evaluation
mechanisms, and counts towards credit points for career advancement. For non-civil servants, training
certificates can be used as documentation to become a certified trainer for STBM training or to become
an STBM implementer.
Indonesia is in the early stage of implementing this system and faces several challenges:
Training and accreditation needs to be rolled out and strengthened across the country;
Capacity of existing sanitarians varies widely and not all are motivated to improve their skills by further
training; and
The scale of the sanitation challenge requires very large numbers of skilled personnel (thousands) and
the output of trainees needs to be increased.
11 Refer to case studies for more detail on integration examples.

Figure 5.7 Institutionalization of capacity building for rural sanitation human resources
PART I 5Findings
STBM
Human resources
Pre-service In-service
health polytechnic students civil servants and professionals
Integration of STBM into curriculum Standardization and accreditation
Subject credits Certificate

Early involvement in local governent Credits
STBM E-Learning: Health polytechnic students, civil servants and professionals,

and the wider public with interest in STBM
Certificate of participation
Source: World Bank (2015) Institutionalization of Rural Sanitation Capacity Building in Indonesia.
Timor-Leste has not only invested a lot of effort into developing a Community Action Plan for Sanitation
and Hygiene (PAKSI) Facilitation Guidebook which is used consistently by all implementers, but also
into establishing a government-accredited 6-day PAKSI Facilitation course through the National Health
Institute. A 10-day Advanced PAKSI Facilitation Training course has also been developed for a Quality
Control Team (government and NGOs), which will be trained to monitor the quality of PAKSI delivery and
provide mentoring support based on identified needs. With help from development partners, the MoH
and the National Health Institute are developing workplace based assessments to assess the quality of
facilitators and identify further training/mentoring needs.
For Viet Nam, a standard CLTS training manual and supporting materials have been developed by MoH
and is used by implementers for training. The College of Agriculture and Rural Development is a centre
for CLTS master training and a database of CLTS master trainers is maintained.
In Cambodia, having CLTS Guidelines on what facilitators are meant to do has been a major factor in
obtaining unity and consistency between implementing agencies. The National CLTS Guidelines provide
a module for facilitators, including selection criteria for facilitators, description of duties and community
procedures. However, implementation is still conducted by NGOs with no systematic follow-up on
facilitator quality except by individual NGOs through performance reviews. A triggering performance
checklist in the guidelines is used by implementers to monitor quality.
At the lowest level of quality, Papua New Guinea and Solomon Islands lack any standard facilitator
training module or consistent approach to facilitator training, and follow-up on quality is very much
dependent on the implementing NGO.
Lao PDR and Timor-Leste are developing a group of very experienced master trainers. This emphasizes
quality rather than the number of facilitators.
In Myanmar and China, the CLTS Guidelines have been translated into the local language without
adaptation, while in Kiribati there has been some tailoring for the country context.

5.3.8 ODF criteria
PART I 5Findings
A comparative review of CLTS in the region highlights whether ODF criteria is consistently applied within
each country and between countries, and also how achieving the criteria is independently verified. Since
2012, there has been an improvement in the definition and verification of ODF within countries through
the documentation of ODF criteria and verification guidelines. However, ODF criteria differs between
countries due to varying policy contexts.
Three factors were found to be important for ensuring consistent application of ODF criteria: (1) official
government endorsement of criteria; (2) sufficient detail and clarity of the guidelines and criteria; and (3)
fewer ODF criteria.
Government endorsed ODF criteria are in use by Indonesia, Timor-Leste, the Philippines, Cambodia and
Lao PDR. As found by Cambodia, when the country recently adopted official ODF guidelines, a common
and consistent approach between implementers became possible something that had been lacking
previously and a cause of frustration by implementers. Kiribati and China use project-based ODF criteria,
but these still need to be developed for Papua New Guinea, Solomon Islands and Mongolia. In countries
where national criteria had not yet been agreed, different implementing agencies were reported to adopt
different criteria and follow different processes, with some reported to be less rigorous than others.
This review has found that guidelines on ODF criteria and the certification process need to be well
thought out with full details on definitions and interpretations, sampling methods and time periods, and
roles and responsibilities so that there can be no uncertainty during the ODF certification process. This
is the case for Cambodia, and both Viet Nam and Myanmar are in the process of finalizing specific ODF
criteria following practical trials of the criteria in the field. Timor-Lestes guidelines are not detailed and the
review found that the criteria for ODF was open to interpretation and not applied consistently between
implementing partners.
Having too many criteria can make verification complex and difficult to achieve. Questions have been
raised about the weighting of other criteria aside from ceasing open defecation, and the need to equally
promote all criteria such as handwashing, to achieve all criteria, not just ending open defecation. For
example, in Lao PDR, verification of handwashing with soap was less strict because this had not been
as thoroughly promoted as a behaviour when compared with ceasing open defecation. This reinforces
the finding from the Plan study that even though open defecation behaviour has been sustained, overall
slippage can be high if several criteria are scored. This is a measurement issue for the sector.
The different ODF criteria in use in the region are shown in Figure 5.8. In some countries, the sharing of
latrines is permitted, provided there is a minimum level of households with their own toilet, e.g., Lao PDR
at 85 per cent.
All countries have weak guidelines when it comes to specifying how, when and who does post ODF
follow-up to improve sustainability. Most guidelines are useful up to the point when a community has
its ODF status verified, with an expectation that follow-up is either not necessary or will just happen. In
some cases, NGOs conduct three or six monthly post ODF checks (even if not required by guidelines),
however, this is limited. This is an area that could be strengthened in future.
5.3.9Technical support
Previous studies have found that market and service access for affordable sanitation products, goods
and services can be a precondition for durable construction, moving up the sanitation ladder and the
sustainable use of sanitation.12 The availability of technical services and sanitation products was included
in this review to further test this finding.
The availability of products and services is generally poor in most countries with limited access to varied
and affordable technical options. In some countries (for example Indonesia and Cambodia) the concept
of a sanitation ladder is not applicable and householders prefer to get a better quality and more durable
toilet if possible, and may defer purchase until they can afford their preference.
12 Documented in IDS (2015) Frontiers of CLTS: Issue 4 CLTS and Sustainability.

Figure 5.8 ODF criteria by country
PART I 5Findings
Safe water/
waste water
Official criteria
Litter free Draft criteria
Informal criteria
HWWS
85% latrines 85% latrines 90% latrines
Toilets Toilets Toilets Toilets Toilets with Toilets with Sanitary

Childrens Childrens Infant Childrens lid lid latrines
faeces faeces faeces faeces No OD HW with Childrens
No OD No OD No OD No OD HW with soap faeces
Community Community Community 80% HW soap or ash No OD No OD
Sanction/ actions Sanction place Sustainability Clean village HW with
plan Action plan Resolution strategy soap
Monitoring Action plan
Indonesia Cambodia Lao PDR Viet Nam Myanmar Kiribati China

Timor-Leste
The Philippines
In some countries, access to a range of products and services is reasonable, but with limited options for
the poorest households and those distant from the sanitation supply. Sanitation marketing is introduced
to varying degrees in Indonesia, the Philippines, Cambodia, Lao PDR, Viet Nam and China.
In Myanmar, Papua New Guinea and Timor-Leste, the sanitation market is underdeveloped with either
limited accessibility to markets by the rural population, very few affordable sanitation options, or both.
Kiribati has a unique challenge of having few viable choices of sanitation technology due to the need to
protect the underground water supply.13 CLTS (and sanitation generally) in challenging environments is
yet to be tackled by the sector.
5.3.10 CLTS monitoring

Basic CLTS monitoring data were not readily available at either national or programme levels. Ten out of
12 review countries struggled to provide current CLTS progress data. By asking countries to report on
triggered and ODF communities (as core indicators of progress), the difficulty in collecting this data was
more revealing about country monitoring systems than the data itself, as the data collection process was
complicated despite the best efforts of review teams.14
Indonesia has an online national monitoring system through STBM that shows triggered and ODF
communities and types of sanitation by location. Lao PDR was able to provide a spreadsheet which had
clear details for all implementers by location and needed only minor number updates.
The lack of a centralized place for consolidating data and monitoring progress in several countries was
striking, especially those with a longer history of CLTS such as Cambodia and Timor-Leste. Timor-Leste
has two data systems Sistema Informasaun Bee no Saneamentu (SIBS) and a Sector Planning Tool
but neither could provide the information required.
Even where CLTS is not a government programme, implementers do not automatically share data in a
central repository, but they could, and should. As a minimum, these data should show which agencies
are working in which locations. A common complaint of government is that they do not know who is
working where, but it appears in several countries neither do sector actors.
13 Refer to study on Kiribati.

14 The
author would like to acknowledge the considerable and urgent efforts made by the country review teams in chasing, collating and verifying the
CLTS progress data used in this review.

Data also needs to be accurate by being current, but also avoid double counting as is highly likely
PART I 5Findings
when implementers report by agency rather than location (e.g., both funding agency and NGOs claim
overlapping ODF achievements), or under counting, where NGOs are implementing CLTS outside of
mainstream reporting.
The review confirms that the limited demand for, and utilization of, these CLTS progress data (or
other sanitation progress data) diminishes incentives to maintain monitoring systems through regular
collection, processing and reporting. Only where there has been a national monitoring system
established is data widely collected, however even in the case of Indonesia, there is little evidence that
the data is analysed and used for decision making or rethinking strategic approaches.
The issues of monitoring data will become more critical with Sustainable Development Goal 6: Ensure
access to water and sanitation for all. The target is:
By 2030, achieve access to adequate and equitable sanitation and hygiene for all and
end open defecation, paying special attention to the needs of women and girls and those
in vulnerable situations.
The conclusion from this review is that countries in the EAP region need to invest much more in
developing and maintaining monitoring systems that can show progress towards this goal and when
open defecation is eliminated.
Post ODF monitoring for sustainability is very rare and has only been carried out in individual programmes
e.g., UNICEFs endline surveys in Timor-Leste. Most countries do not have the systematic follow-up of
ODF communities to monitor slippage.
5.3.11Evaluations
Forms of evaluations and reviews of CLTS range from periodic meetings amongst implementers to
independent consultant reviews of programmes, and annual sector reviews. However a number of
countries have yet to critically assess performance.
There is extremely limited or useful information on the costs of achieving ODF communities, despite
this being necessary prerequisite information for developing strategic plans and scaling up to reach
larger ODF targets. By simply asking the question of how much it cost to implement CLTS, the answers
showed there is a lack of information sharing within countries, differences in how costs were calculated
(were per diems included, etc.), and thus wild differences in estimates. If CLTS is to be justified as a cost
effective approach to sanitation then much more effort is needed in developing comprehensive costs
norms, and then analysing whether CLTS is a value for money approach.
Only Lao PDR was able to clearly express the delivery cost, and what stages and activities were included
in the costs, but also estimated the costs for scaling up.
All cost estimates were programme delivery costs for reaching ODF and did not consider additional costs
such as verification, supervision and monitoring.
5.4 REGIONAL CLTS PROGRESS OVERVIEW

5.4.1 Most significant change
Each country was canvassed on what it thought was the most significant change to occur in developing
CLTS since 2012. The most significant changes have been in attitudes towards, and greater acceptance
of, CLTS, reform of the enabling environment, and strengthening of CLTS practice. These changes are
common among countries and are summarized as follows:
All changes recorded were positive. Several created breakthroughs which can lead to further
development, e.g., passing the National WASH policy in Papua New Guinea has created the potential for
not only the development of the WASH sector generally, but also the acceptance of CLTS as an approach
which can be widely adopted.

Table 5.6 Most significant changes in the last three years
PART I 5Findings
Papua
DPR Lao New The Solomon Timor- Viet
CHANGE Cambodia China Indonesia Kiribati Korea PDR Mongolia Myanmar Guinea Philippines Islands Leste Nam
Wider acceptance u u u u u u
of CLTS/change in
thinking
Increased u u
government
ownership/
commitment
Passing of National u u u
policy
Development of u u u u u
National CLTS
guidelines
Increased spread of u u u u u
CLTS/scaling up
More trained u u u
facilitators/better
facilitation/new
triggering
Better access to u u
sanitation products/
sanitation marketing
Improved u u
coordination
Improved monitoring u u
Integration in to u u
other programmes
5.4.2 Lessons learned

Although lessons learned are as diverse as each country context, maturity and scale of CLTS
implementation, there are some common themes that emerged.
Government commitment recognition by governments (both national and local) of the need to achieve
ODF communities and having targets directed at this goal are fundamental for moving CLTS forward. In
Viet Nam, government commitment to become ODF by 2025 has resulted in CLTS being mainstreamed
into large sanitation programmes. In Indonesia, commitments by provincial governors and district
leaders to become ODF have resulted in regulations that filter down to the lower levels of government
and unlock budget and resources for implementation and monitoring of sanitation efforts. In China,
government officials involved in CATS project implementation are positively disposed towards scaling up
compared to their counterparts in non-project areas. Kiribati has found that a constant commitment by
Island Councils to monitoring, verifying and checking ODF communities is needed to sustain behaviour
change for the long term. In both Timor-Leste and Myanmar, the lack of government commitment and
associated budget and human resources is seen as holding back the scaling up of CLTS and taking it
beyond the hands of development partners and NGOs into a national approach.
Triggering quality and capacity the quality of facilitators and their skill in triggering to influence
behaviour change remains a cornerstone in CLTS practice, as well as an on-going challenge. The need for
well trained facilitators, including from governments, with regular refresher training was noted in
Myanmar, Mongolia and Lao PDR. Viet Nam found that the lack of systematic reviews of facilitator
performance and uneven support and monitoring of facilitators undermined triggering quality. Lao PDR
and the Philippines identified the need for on-going mentoring support and monitoring for CLTS
facilitators to be incorporated into plans and budgets for scaling up. The Philippines also found that
selecting good quality facilitators in the first place (through wide talent searches and prequalification
before training) helped ensure effectiveness of triggering during rollout.

Sanitation hardware most countries now acknowledge that sanitation hardware is an important
PART I 5Findings
component in the improved sustainability of ODF communities, and in fact several would like to have this
aspect strengthened through sanitation marketing. CLTS can no longer be seen as a stand-alone process.
In Myanmar, construction of low quality latrines with pits that flood in high water table areas or collapse
in sandy soils resulted in reversion to open defecation. In Indonesia, one of the reasons for slippage is
that the toilet is not what the household wants and it deteriorates over time and is abandoned. In
Lao PDR, there remains a strong preference for pour-flush latrines, which are unaffordable to most poor
households. Technical assistance in the design and marketing of more affordable, hygienic latrines would
potentially be very useful and help to make scaling up possible. In Viet Nam, the availability of low-cost,
socio-culturally appropriate latrine options using locally available materials has helped increase sanitation
for a wider range of people with different levels of affordability and has made CLTS more effective. In the
Philippines, sanitation marketing that introduces low cost and easy-to-construct toilets after triggering
has helped dispel myths about the high cost of toilets. Cambodia has found that if CLTS and sanitation
marketing are integrated, then the achievements can be quick and sustainability can be improved.
5.5 KEY ISSUES

5.5.1 Urbanization and CLTS
CLTS has long been regarded as a rural approach to sanitation, however it is increasingly being piloted
and implemented in urban and peri-urban areas, most recently in settlements in Nairobi, peri-urban
communities in Eritrea, low income communities in Kenya, small towns in Ghana, and cities in India,
Zambia and Mauritania. Within the EAP region, CLTS is being deployed as part of a complete urban
sanitation approach in Indonesia and in settlements and peri-urban communities in the Solomon Islands
(see case studies). Other countries in the region are also implementing CLTS on a limited scale in
peri-urban areas or district and subdistrict centres, usually on a pilot basis by an NGO or because the
scope of a rural sanitation programme encroaches into peri-urban areas. The countries beginning to test
urban CLTS approaches are: Mongolia, Papua New Guinea, the Philippines, Timor-Leste and Viet Nam.
Experience with CLTS in urban environments provides consistent feedback on the need to adapt CLTS to
an urban context where there is less community cohesion and more technical constraints. Some of the
common challenges with implementing CLTS in urban settings include:
The large size of urban communities and their heterogeneity necessitates more intense and time
consuming engagement;
Open defection is not necessarily related to a lack of toilets but how faecal waste is managed and
disposed;
More people participate in the wage economy and are less available to attend triggering sessions and
participate in other ways;
Sanitation standards are higher for urban areas and toilets are more costly;
Often there is a lack of space to construct latrines;
Tenants and those without secure land tenure are unwilling to construct latrines;
Institutional leadership is critical, including local government leaders and church leaders;
Local regulations are usually needed to reinforce change; and
Pit emptying, sludge removal and other maintenance have to be planned for.
Where the CLTS method has been adapted for the urban context, some of the outcomes from urban
CLTS have been: increased community awareness of sanitation impacts, a reduction in open defecation,
increase in landlords building toilets for tenants, space being provided for communal toilets, and the
empowerment of womens organizations. In several communities, the management of solid waste has
also improved as a result of community mobilization arising from CLTS.
Urbanization is already a significant trend in several countries in the EAP region. Countries such as
Indonesia and China have declining numbers of people living in rural areas, both in real terms of the
number of people, but also in percentage terms (see Table 5.7). Indonesia now has more people living

Table 5.7 Selected urbanization rates
PART I 5Findings
URBAN URBAN
% URBAN % URBAN % URBAN POPULATION POPULATION
POPULATION POPULATION POPULATION 000 000
COUNTRY 2000 2015 2030 2015 2030
China 35.9 55.6 68.7 779,479 998,925
Indonesia 42.0 53.7 63.0 137,422 184,912
The Philippines 48.0 44.4 46.3 45,173 59,220
Lao PDR 22.0 38.6 50.9 2,711 4,479
Papua New Guinea 13.2 13.0 15.0 993 1,503
Solomon Islands 15.8 22.3 28.6 131 218
Source: UN Population Division, (2014) World Urbanisation Prospects, Annual Percentage of Population at Mid-Year Residing in Urban Areas.
in urban areas than rural areas (53.7 per cent in 2015 compared to 42 per cent in 2000).15 The predictions
for the number of people requiring access to improved sanitation in urban areas in the next 15 years
indicates a looming challenge on the horizon. Even in small countries such as Papua New Guinea, an
additional 500,000 people in urban areas will put pressure on already inadequate sanitation services.
It is likely that urban CLTS will develop further as a sub-practice out of the need to address sanitation
in low-income urban areas in the region. There is an opportunity to learn from the growing body of
experience with urban CLTS within the EAP region, and in other regions such as Africa.
5.5.2 Adaptation of CLTS

CLTS is increasingly being applied as an approach within broad sanitation programmes to spark disgust
and other emotions that motivate communities to change behaviour. Application of pure CLTS is being
overtaken by CLTS integration into total sanitation approaches. The unique contribution that CLTS can
make is recognized, but the need for sanitation marketing and institutional development are also seen as
part of the total picture to improve and sustain sanitation.
In the Philippines, CLTS is applied in the Scaling Up Rural Sanitation Program primarily as an approach for
creating sanitation demand in targeted poor communities. LGUs are taught how to target and prioritize
barangays where the CLTS approach can be used as tool for igniting behaviour change in sanitation and
hygiene practices.
5.5.3 Use of incentives and sanctions to reinforce social norms

Countries in the region have a range of experience with incentives and sanctions to reinforce ODF
communities. These carrots and sticks are generally created locally by the community itself, or within
the context of ODF certification and recognition. This means incentives and rewards are appropriate
for individual communities, while it also means that the application of incentives and sanctions varies
across a country and between implementers. Only where there are national programmes for Healthy
Villages (Pacific), Model Villages (Viet Nam), and Barangay with Best Sanitation Practices (the Philippines)
and other similar programmes, are rewards and incentives formalized. In Timor-Leste, the national
sanitation policy provides an opportunity for incentives for ODF villages, however no national system
for implementing these incentives has been established. For other programmes e.g., the Presidents
Community Nutrition Award, village ODF status is required, but is omitted from the Hygienic Suco
Programme that focuses on solid waste removal.
Findings suggest that in terms of incentives and rewards, village-level collective incentives and rewards
work best. Where individual community members receive gifts or other incentives, this creates problems
for implementation in a community. Incentives and rewards do not have to be monetary based, with
recognition, particularly from higher authorities outside of the village, being effective.
Communities usually devise their own sanctions, regulations and fines, but in most cases fines are not
implemented because it is rare that they are needed as behaviour has changed before this point.
15 UN Population Division, (2014) World Urbanisation Prospects, Annual Percentage of Population at Mid-Year Residing in Urban Areas.

The range of incentives, rewards, and sanctions includes:16
PART I 5Findings
Encouragement from influencers

Local and higher level government issuing letters of encouragement to stop open defecation
(Cambodia); or convincing/encouraging households to build a toilet (the Philippines).
Role modelling of toilet ownership and use by sanitation sales agent (Cambodia).
Public shaming and peer pressure

Development and display of a village sanitation map (Cambodia, the Philippines).
Publically listing households without toilets (and displaying the list at a community store, rural health
unit) (the Philippines).
Households with a toilet encourage other households to adopt the use of toilets/cease open
defecation (Viet Nam) and peer pressure from households with toilets to those without (the
Philippines).
Diaries/journals from individual households on their commitment to build toilets (the Philippines).
Public accountability and reporting on sanitation at local government meetings (Cambodia).
Targeted messaging
Linking sanitation messages with administration processes, e.g., when people want approval letters
for marriage or to build a new house they are encouraged to build a latrine first (Cambodia).
Sanitation and hygiene messages through schools (Cambodia).
Recognition of achievement
Village receives a Certificate of ODF (Cambodia, Viet Nam, Lao PDR, Myanmar) (this is particularly
effective if the certificate is awarded by district or provincial government).
Displaying a signboard which highlights the village has achieved ODF status (Cambodia, Papua New
Guinea, Myanmar).
Award a community with the status of a cultural village (Viet Nam).
Formal commitments and contracts

Public declaration or signed pledge by the community of its commitment to cease open defecation
(Indonesia, the Philippines, Viet Nam) (This may include pledges signed by all households, or a
community-wide pledge signed by the village head).
Village regulations (Indonesia) and the creation of sanitation ordinances reinforcing the continuous
use of sanitary latrines in communities (the Philippines).
Traditional local law Tara Bandhu applied against open defecation with sanctions for community
members who openly defecate. During the ODF declaration ceremony, the local leaders take an oath
to ensure that their community maintains ODF status (Timor-Leste).
Signing of a social contract to maintain ODF status once a village is declared ODF (the Philippines).
Rewards
Cash and in-kind materials (e.g., toilet bowls, PVC pipes) given by the municipal office for a village to
be able to move from ODF (Grade 1) to the Grade 2 level of Sustainable Sanitation (all households
have hygienic toilets and institutions have sustainable toilets). Rewards given by the municipal office
are later shared to the community through targeted subsidies aimed at the poorest families
(the Philippines).
Rewards for whole villages including gifts of soap, hand washing devices, water filters, loudspeakers
to leaders in communes/villages (Viet Nam).
16 Source: Country Status update questionnaire.

National level rewards through the Department of Health for the winners of the National Search
PART I 5Findings
for the Barangay with Best Sanitation Practices (the Philippines). The award gives recognition to
barangays (villages) that have demonstrated exemplary contributions in helping to obtain and sustain
targets under the MDGs on WASH, and have demonstrated good environmental sanitation practices.
Barangays are judged based on several weighted criteria: sanitary toilets, 25 per cent; water supply,
25 per cent; improvement in toilet coverage, 25 per cent; approved barangay budget for water and
sanitation projects and programmes, 10 per cent; and other local sanitation initiatives/projects,
15 per cent.
ODF achievement is linked with receiving water supply improvement (Indonesia, Papua New Guinea).
Fines
Community-imposed fines for open defecation (Cambodia; Kiribati, Papua New Guinea, Lao PDR). In
parts of Kiribati, half of the US$ 5 fine goes to a general sanitation fund and half goes to the person
who caught the open defecator. In Lao PDR, although mechanisms for fines exist, they have rarely
been enacted as they turn out to be unnecessary.
Fines for households leaving animals wandering around and polluting their village (Viet Nam).
Fines for households without toilets (the Philippines, Papua New Guinea) (This was found effective
in most rural areas in North Cotabato, in the Philippines, but not in the way expected. Households
without a toilet would be fined, but due to shame, the fine money would be used by the household
to build a toilet).
An example from Papua New Guinea highlights the use of practical incentives and rewards for external
volunteers who support the promotion of sanitation and hygiene in villages to maintain interest and
commitment. The NGO Touching the Untouchables has been providing Community Health Post staff
and village birth attendants with uniforms, identification cards and certificates of completion of training
and ODF status, as well as footwear and second hand clothing when possible. The district health
service provides free transportation for volunteers whenever they are travelling through the local level
government area or visiting CLTS villages. These incentives help to strengthen teamwork and visibly
reinforce the seriousness given to having good toilets and improving sanitary and hygienic practises.
5.5.4 Local actors

This review has been able to explore the role of local actors in CLTS. The findings are that local actors are
immensely important to all stages of the CLTS process. Their roles range from influencing, empowering,
supporting, helping, monitoring, following up and reporting on CLTS activities in a community. They
are fundamental to the role of the facilitator and field staff, and can follow up after triggering and keep
the community on track after the facilitator has departed. Key local actors are village leaders, teachers,
women (including womens associations and unions), youth, medical staff, and religious leaders
(Christian, Islam, Buddhist).
In Lao PDR, facilitators need the support of local actors (e.g., natural leaders and village leaders) to call
on representatives from each household to attend triggering activities. During post triggering, local actors
also play a crucial role in supporting the follow-up and monitoring of agreed actions by the communities,
including establishing village rules on toilets and their use. In the Philippines, natural leaders help village
leaders by supporting the community to develop its Zero Open Defecation (ZOD) Plan and then follow up
the plans implementation, including through informal influencing. Teachers provide a key link to schools
by reinforcing the importance of latrines as part of hygiene education, empowering children to become
messengers to their parents, and supporting school sanitation improvement.
Feedback concludes that natural leaders and local actors should be brought into the CLTS process as
early as possible from first triggering, if not before. They should be invited to actively participate in
triggering sessions. The benefit from involving local actors is that they can directly influence village plans,
but also influence behaviour change through their regular interactions with the community.
The following word cloud highlights the types of local actors and their roles.

Figure 5.9 Word cloud on local actors and their roles
PART I 5Findings
5.5.5Time to reach ODF

The time between triggering and a community declaring ODF is between one month and 12 months.
Some communities, despite intensive triggering and follow-up, have not reached ODF status after more
than 12 months. Indonesia reported a case where a community had not reached ODF since 2008,
while one community in the Philippines took five years to reach ODF. Factors which help quicken the
achievement of ODF are: activeness of village authorities and established village CLTS committee;
close post-triggering follow-up by facilitators and mobilization work done by the village CLTS committee;
availability of sanitation options/materials/suppliers; and absence of technically challenging environments
such as flood prone areas. The presence of subsidies in neighbouring villages or districts can inhibit
communities becoming ODF as they take no action in expectation of a subsidy.
The shortest and longest times for ODF achievement by country are shown in Figure 5.9, together
with the typical or average time point (generally three to eight months). Additional time is needed for
verification and certification processes and also front-end pre-triggering activities, meaning for some
countries, the total time in which to achieve ODF may be over 12 months.
5.5.6Subsidies
The provision of subsidies for sanitation continues to undermine CLTS in some countries, particularly
where there is a transition towards non-subsidized approaches and practice has not caught up with
policy. Upfront hardware subsidies on toilets have negative impacts on the CLTS approach because they
create a culture of dependency for nearby villages who wait for handouts before they take action on
sanitation. In some countries, national policy directs non-subsidized sanitation, with targeted subsidies
for poor households, but this has not been implemented yet.
For example, the Solomon Islands national WASH policy states that subsidies will still be considered
where the only environmentally appropriate technical solution falls outside the financial means of the
average household (e.g., compost toilets, toilets suitable for people with disabilities), education facilities
and health facilities. However, subsidies continue to be provided by some organizations for sanitation
hardware, often linked to political objectives.

Figure 5.10Time to reach ODF from triggering (months)
PART I 5Findings
14
12
10
Cambodia Indonesia Kiribati Lao PDR Mongolia Myanmar Papua The Timor- Viet Nam
New Guinea Philippines Leste
Shortest Longest Typical
Some national CLTS programmes such as the STBM in Indonesia exclude the use of any subsidies, with
intra village help organized informally with cross subsidization of the poor by the rich or other community
support systems.
A grey area impacting on CLTS are subsidies provided during and after an emergency. This has been
disruptive in the Solomon Islands and Myanmar, but in the Philippines, CLTS combined with small,
targeted subsidies for vulnerable households in post-cyclone emergencies has been relatively effective,
although the delivery and timing of the subsidies varied between implementers and caused some public
confusion (refer to case study).
A number of countries are considering the use of targeted partial subsidies for very poor households with
no capacity to build a toilet. The general preference is that these subsidies are provided once households
have and use their own toilet, or by applying some form of smart subsidy. An argument proposed by
the Philippines is that waiting for very poor households to save enough to afford constructing their own
toilets may have a greater negative impact on the community than exercising a smart subsidy that would
propel the community to be ODF.
Overall there has been a greater acceptance of the need to have some assistance for the poor through
highly targeted subsidies that are equitably and transparently applied. However no country has yet
systematically or successfully adopted a subsidy process, although some are experimenting. This area
warrants further inquiry and monitoring in the future. There are learnings to be drawn from the
Philippines approach to subsidies following Typhoon Haiyan; Viet Nam will experiment further with
rewards through the Scaling Up Sanitation Program; and Timor-Leste has considered a social scheme in
the past.
Targeting of the poor, who are the least likely to have access to sanitation, may require subsidies of some
form, however most implementers would agree that more thought needs to go into the type and timing
of subsidies, and that any subsidy programme needs to be equitable, accountable and transparent, and
linked to positive behaviour changes.

5.5.7 Support for the poor
PART I 5Findings
Support for the poor to gain access to sanitation through CLTS is currently ad hoc. In Myanmar, village
leaders can generate community support for individuals in the form of labour, materials or cash, but this
depends on the strength of the local leader. In the Philippines, UNICEF and partner NGOs develop the
capacity of local leaders to collaborate with sanitation suppliers on hardware price, cost efficient delivery
to remote areas, and identifying credit options.
Despite some challenges with attracting microfinance institutes (MFIs) to sanitation, loans are a potential
alternative option for the poor to access sanitation, provided the conditions for collateral are not too
onerous and repayments are feasible. Even in Typhoon Haiyan-affected areas in Tacloban, the Philippines,
poor households are taking out loans for toilets. Toilet loans are also made available through the Viet Nam
Bank for Social Policy. In a WSP pilot area in the Philippines, a local Micro Financing Co The Negros
Women for Tomorrow has developed a Sanitation Loan programme, which is a special loan for women
who have been members of the fund for more than two years and have a history of making repayments.
Loans can be taken at 2.5 per cent interest per month, with a loan term of three to 12 months to build
two different toilet package options costing US$ 108 (for a pour flush toilet with concrete slabs and rings)
and up to US$ 210.
In Indonesia, support for poor households is largely through self-help community groups such as savings
and loan groups. The local production of sanitation components is also employed to help create equitable
access to sanitation.
It is rare to find villages with excess funds for sanitation that can be redirected to the poor, although
Papua province in Indonesia has large Special Autonomy funding from national and subnational
government for village development. The challenge then becomes how to influence the use of these
village funds to support the poorest households to access sanitation facilities. UNICEF has been
successful in influencing that these funds be used for sanitation activities, especially STBM, with the
Governor decreeing that a proportion of the health funds earmarked from the Special Autonomy must be
used towards STBM. This type of advocacy approach to redirect funding sources may also be applicable
in other places where there are large injections of cash, such as villages with royalties from extractive
resources in Papua New Guinea.
5.5.8Diffusion
There is some evidence of diffusion from CLTS communities to non-CLTS communities, however the
scale is quite limited. The main methods of diffusion are through local governments replicating CLTS in
non-programme areas, local sanitation champions spreading the word, friends and family from nearby
villages visiting CLTS villages or attending triggering sessions, and publicity through the media.
In the Philippines and Indonesia, local and district governments have been taking the initiative to go
beyond programme-supported areas and have triggered other villages. In the Philippines, it has even
been reported that some villages have declared ODF without even being triggered, apparently because
the community heard the benefits that the nearby communities have been enjoying and also decided
to build toilets on their own so that nobody defecates in the open and their village can also be clean and
free of diseases. Local sanitation champions such as local chief executives who are strong believers of
the CLTS approach are sharing their own stories and narratives to other local chief executives from other
provinces and towns.
In both Viet Nam and Papua New Guinea, visitors from non-CLTS villages or bordering villages have been
impressed by the triggering process and sanitation improvements in CLTS villages, and feel a sense of
competition to improve their own communities.
Media are also having some impact on diffusion through publicity of sanitation news.

6CONCLUSIONS
PART I 6Conclusions
This second review of CLTS in the EAP region finds that CLTS continues to play an important role in
achieving reduction in open defecation and uptake of sanitation. But exactly what is this contribution?
Much of the value of CLTS is in the collective response to ending open defecation as has been shown
by the importance of everyone in a village having improved sanitation to protect against environmental
enteropathy and child stunting. A numerical analysis of CLTS contribution to reducing open defecation in
individual countries is unreliable due to incomplete data and competing population growth. However a
basic calculation for Indonesia shows that the 3,140 villages that achieved ODF status between 2012 and
2015 using the local CLTS method (STBM) contributed most of the gains to the 4,000,000 people who
ceased open defecation between 2012 and 2015 (from JMP estimates).
Changes in CLTS in the region over the last three years include greater recognition at government level
of CLTS as a viable approach; evidenced by the embedding of CLTS in sanitation policies and strategies.
Eight of the 12 implementing countries have policies that recognize and promote CLTS, where previously
only three countries did. Interestingly, some recent policies permit and encourage subsidies or targeted
assistance for the poor in recognition of the difficulty the poor have in accessing sustainable sanitation.
Other developments include implementation guidelines and ODF criteria to help institutionalize CLTS as a
common and consistent approach, as well as more standardizations of facilitator training. The importance
of government ownership can be seen by the progress of countries that have recently taken up CLTS
such as Kiribati that progress can be quick when the government is behind the effort. Governments are
essential for scaling up.
In recent years there have been some promising new developments and trends in CLTS that should be
monitored in the future such as:
Application of modified CLTS in urban areas;
CLTS in post emergency situations;
Better targeting of the poor, for example, through social welfare programmes which
integrate sanitation;
Efforts for improving the sanitation supply side, for example, through promotion of
sanitation marketing;
Ongoing attempts at integrating CLTS with nutrition programmes regarding interventions on hygiene
promotion, hand washing and other hygiene behaviours, WASH in schools; and
The use of microfinance to help the poor.
However challenges remain which need to be addressed:

Governments are not doing enough to finance CLTS in many cases, governments are not backing
CLTS by funding implementation, monitoring and knowledge sharing.
Poor strategies exist for rolling out sanitation, including reaching ODF goals. There is often a
disconnect between the political targets for sanitation and the practicalities of reaching those targets
through CLTS.
The extent to which sanitation monitoring systems are adequate in capturing data on the
implementation progress of CLTS and the number of ODF communities, especially in forthcoming
SDGs and universal access contexts. With regards to CLTS, it also seems important to focus on the
practice of CLTS (e.g., from triggering to follow-up with communities in becoming ODF, follow-up
monitoring on slippage, ensuring inclusiveness/participation, etc.).
ODF verification and certification processes, together with ODF criteria, are still lacking in some
countries, and no country has addressed post ODF follow up.
More work is needed on integrating CLTS with sanitation marketing and improving access to
sanitation products and services that meet different needs.

Sanitation and CLTS in challenging environments, e.g., flood prone areas, high water table areas and
PART I 6Conclusions
disaster prone areas are yet to be tackled at any scale, despite many people in the region living in
No country has systematically adopted pro-poor support processes within CLTS yet, although some
are experimenting.
Reliable information about the cost of CLTS is absent. Without this information, it is difficult to
advocate to governments that CLTS is a cost effective approach which should be supported.
CLTS is seen as a largely rural approach to sanitation, yet urban populations are growing in the
region and have considerable sanitation challenges with increasing poor populations and higher living
densities. The challenge is how to take the demand creation aspect of CLTS and adapt the approach,
combined with sanitation solutions and business models to make it fit to an urban context.
CLTS information sharing within the region is ongoing, however this could still be further
strengthened. Unfortunately, there has not been a continuation of the EASAN, which in the past,
provided the opportunity for regional sanitation exchange events. On the other hand, several
organizations have continued undertaking exchanges/learning events/study tours, indicating the need
for more opportunities for the sharing of practices and paired learning between countries with similar
levels of development and CLTS implementation.
For the region looking forward, two points should be considered:
Generalizing about the region as a whole is not particularly helpful, given its extreme range of size and
the situations of the countries within the region, but there is diversity of experience available. Indonesia
still remains the largest implementer of CLTS and there is much to learn from this country in terms of
government approach, monitoring, scale of triggering and ODF communities. However, Indonesias
persistently high open defecation and child stunting rates suggest that Indonesia may not have all the
answers, despite it having a rich range of experiences. New and emerging countries implementing CLTS
may provide fresh insights.
CLTS continues to be effective through its core attributes of triggering behaviour change and generating
collective action. But is there a risk of CLTS fatigue and a loss of interest in the approach in future? Or is
it that CLTS becomes so much a part of the way sanitation is achieved that it is no longer singled out as
an approach? Ultimately this will depend on each country and their own dynamic.

REFERENCES
PART I References
Cavill, S. with Chambers, R. and Vernon, N. (2015) Sustainability and CLTS: Taking Stock, Frontiers of
CLTS: Innovations and Insights Issue 4, Brighton: IDS.
Chambers R. and von Medeazza G. (2014) Reframing Undernutrition: Faecally-Transmitted Infections and
the 5 As. IDS Working Paper Volume 2014 No 450.
Coffey D., Gupta A., Hathi P., Khurana N., Spears D., Srivastav N., and Vyas S. (2014) Squat Survey Research
Paper 1 - Revealed preference for open defecation: Evidence from a new survey in rural north India.
Final report: Impact evaluation of Community-Led Total Sanitation (CLTS) in rural Mali (2014).
JMP (2012) Progress on drinking water and sanitation Geneva and New York: WHO-UNICEF Joint
Monitoring Programme for Water Supply and Sanitation.
JMP (2015) Progress on drinking water and sanitation: 2015 Update and MDG Assessment Geneva and
New York: WHO-UNICEF Joint Monitoring Programme for Water Supply and Sanitation.
Plan Indonesia, 2012, Improving CLTS from a Community Perspective Approach in Indonesia.
Plan International USA and The Water Institute at UNC Testing CLTS Approaches for Scalability (TCAS )
Project (2011-ongoing).
Quattri M., Smets S. (2014) Lack of Community-Level improved sanitation causes stunting in rural villages in
Lao PDR and Viet Nam. Conference paper for 37th WEDC Conference, September 2014, Hanoi, Viet Nam.
Spears D (2012) Sanitation and open defecation explain international variation in childrens height:
evidence from 140 nationally representative household surveys RICE working paper.
Spears D (2012a) Policy lessons from implementing Indias Total Sanitation Campaign New Delhi: National
Council of Applied Economic Research, India Policy Forum 2012.
Spears D, Ghosh A, Cumming O (2013) Open Defecation and Childhood Stunting in India: An Ecological
Analysis of New Data from 112 Districts. PLoS ONE 8(9): e73784. doi:10.1371/journal.pone.0073784
Spears, D (2013) The nutritional value of toilets: How much international variation in child height can
sanitation explain?
Spears, D. (2013) The nutritional value of toilets: How much international variation in child height can
sanitation explain?
Squat Survey (2014) Policy Brief No. 1 What can be done to end Open Defecation?
Squat Survey (2014) Research Brief No. 1 Ending Open Defecation Requires Changing Minds
http://squatreport.in
Tynedale-Brisco P., Bond M., Kidd R. (2013) ODF Sustainability Study. Plan International.
http://www.communityledtotalsanitation.org/resource/odf-sustainability-study-plan
UNICEF (2014) Evaluation of the Wash Sector Strategy Community Approaches to Total Sanitation
(CATS) - Final Evaluation Report. United Nations Childrens Fund: New York.
UNICEF 2015 Review of STBM in Aceh Timur.
United Nations Population Division, Department of Economic and Social Affairs (2014), World Urbanization
Prospects: The 2014 Revision File 20: Annual Rural Population at Mid-Year by Major Area, Region and
Country, 1950-2050.
Venkataramanan V. (2012) Testing CLTS Approaches for Scalability - Systematic Literature Review (Grey
Literature). Plan/UNC Water Institute.
World Bank (2015) Interim Implementation Completion and Results Report for Indonesia PAMSIMAS Project.
World Bank Water and Sanitation Program, 2014, Water Supply and Sanitation in Indonesia Service
Delivery Assessment.
WSP (2014) Investing in the Next Generation: Children grow taller, and smarter, in rural, mountainous
villages of Viet Nam where community members use improved sanitation. Scaling Up Rural Sanitation
Research Brief.
WSP (2014) Investing in the Next Generation: Children grow taller, and smarter, in rural villages of Lao
PDR where all community members use improved sanitation. Scaling Up Rural Sanitation Research Brief.

PART II
ANNEX 1: COUNTRY CLTS OVERVIEW
A Cambodia Country CLTS Overview
B China Country CLTS Overview
C DPR Korea Country CLTS Overview
D Indonesia Country CLTS Overview
E Kiribati Country CLTS Overview
F Lao PDR Country CLTS Overview
G Mongolia Country CLTS Overview
H Myanmar Country CLTS Overview
I The Philippines Country CLTS Overview
J Papua New Guinea Country CLTS Overview
K Solomon Islands Country CLTS Overview
L Timor-Leste Country CLTS Overview
M Vanuatu Country CLTS Overview
N Viet Nam Country CLTS Overview

PART II ANNEX 1: Country CLTS overview

CAMBODIA
CAMBODIA: Country CLTS overview
CLTS summary JMP estimate:
Rural sanitation
2012 2015
100
Status and CLTS date of introduction 2004 Not yet
scale
CLTS spread: % of country 48% 76%
90
CLTS in urban areas No No
CLTS coverage: major organizations 16 19 80
OD population rural (2010 and 2015, mill) 8.1 m 7.5 m
Villages triggered (number) 1,502 6,160 70 60
ODF villages (number) 608 1,494

Capacity developed (trained facilitators) 214 260 60 82
Enabling CLTS in government policy Yes Yes

50
CLTS targets in government plans No No
CLTS financed by government Indirect Some
40
CLTS integrated with other approaches May be Yes 3
CLTS sustainable monitoring May be No 7
30
Effectiveness ODF success rate 40% 24%
20
6
Scale of rural sanitation challenge 2 30
10
2015 Rural sanitation coverage
2012 10
Category Per cent Households Population Population 0
Open defecation 60% 1,553,542 7,457,002 8,132,400 2000 2015
Unimproved sanitation facilities 3% 77,677 372,850 451,800 Open defecation
Shared sanitation facilities 7% 181,247 869,984 451,800 Unimproved sanitation

Total without improved sanitation 70% 1,812,466 8,699,835 9,036,000 facilities
Shared sanitation
Source: 2015 JMP estimate; United Nations Population Division (2014) Annual Rural Population 2015; 2012 UN facilities
Population Forecast. Improved sanitation
Rural: improved sanitation coverage

The JMP estimate suggests a steady increase in improved sanitation coverage in rural areas since 2000
from 10 per cent to 30 per cent in 2015. Open defecation has reduced from 82 per cent to 60 per cent
and estimates suggest that more than 1.6 million rural households (7.5 million people) do not use any
form of sanitation facility.
National development plans set the goal of 30 per cent rural sanitation coverage by 2015, and
100 per cent by 2025. The JMP estimates for 2015 suggest Cambodia has met its own 2015 goal,
however the National Strategic Development Plan goal of 60 per cent by 2018 will still require
rapid acceleration.
Where is CLTS implemented and by whom
CLTS status and geographic spread

CLTS was first introduced by CONCERN Worldwide in 2004, but without immediate follow up. UNICEF
and Plan Cambodia started to implement at a larger scale in 2006. In 2012, CLTS had spread to 11 out of
23 provinces in Cambodia (introduced in 48 per cent of the provinces), and is now currently in 19 out of

25 provinces and the capital (increasing spread to 76 per cent). Provinces include: Banteaymeanchey,
Battambang, Kampong Cham, Kampong Chhnang, Kampong Speu, Kampong Thom, Kampot, Kandal,
Mondulkiri, Otdar Meanchey, Pailin, Preah Vihear, Prey Veng, Pursat, Rattanakiri, Siem Reap, Svay Rieng,
Takeo and Tboung Khmum.
CLTS institutional coverage
National NGOs International NGOs Bilateral programmes Multi-lateral agencies Government
NAS KYA USAID

Plan Nourish UNICEF
RWC
MRD
CHED Rural Health Care
PDAO (PDRD)
Santi World
Sena Vision SNV
SP GSF
CFED CR-SHIP
Water (Plan)
CRC CESVI Aid WSP
COCD
Major funding through the Global Sanitation Fund (GSF), Cambodia Rural
MAJOR EXCEPTIONS
Sanitation and Hygiene Improvement Program (CR-SHIP 2012-2015), and Programmes with
UNICEFs WASH programme have contributed to expansions in CLTS in both subsidy elements:
spread in the country and number of implementers. UNICEFs WASH Multilateral: ADB RWSSP-2
programme is implemented by the Ministry of Rural Development, through International NGO: EMW
CHOBA
the Provincial Department of Rural Development, and covers 11 provinces. Sanitation marketing
CR-SHIP has reached five provinces but a three year expansion from
2015-2018 will see it reach five more. Under CR-SHIP, the number of national
NGOs implementing CLTS has increased. Since 2012, the number of
international NGOs has consolidated.
CLTS is not currently implemented in urban areas in Cambodia.
Major non-CLTS programmes

A few major implementation programmes in Cambodia have used a subsidy-based approach, notably the
ADB RWSSP-2 (US$ 5.25 million sanitation component).
ADB RWSSP-2: a programme methodology based around a CLTS-hybrid approach that is intended
to use elements from the CLTS approach to create sanitation demand, which is followed by project
support (subsidies) for latrine construction. The project design envisaged that a US$ 75 sanitation
grant will be provided to each household covering the cost of an improved and hygienic dry-pit latrine
with a concrete ring-lined pit (sub-ground structure only). The sanitation grant may be applied in the
construction of a water-sealed or a pour-flush latrine based on household preference and
affordability levels. In practice, the sanitation grant is a prominent feature of the programme with
support for latrine construction and may start before a village achieves 100 per cent open defecation
free status.
East Meets West is implementing Community Hygiene Output Based Aid (CHOBA) (2012-2016) in
five provinces. CHOBA encourages households to build improved household sanitation facilities and
connect them with both approved local construction contractors and consumer lenders. Households
are offered a consumer rebate (or an upfront discount when the rebate is channelled through
suppliers) upon verification of a properly built and used toilet with an associated handwashing station,
and financial rewards are offered for the achievement of community-wide improved sanitation
coverage benchmarks.

Two main organizations, iDE and WaterSHED, are implementing sanitation marketing programmes in
15 provinces which are designed to generate demand for pour-flush toilets, strengthen the supply of
sanitation goods and services, and assist local producers and their sales networks to sell toilets that
increase the number of the population using improved sanitation facilities. These programmes have
utilized some CLTS inspired tools in demand creation and latrine promotion activities, but the main
objective of these sanitation marketing programmes is incremental increases in sanitation coverage
through private toilet sales. These programmes do not have collective action goals (ODF community
targets) and contain few specific pro-poor or equity objectives. The World Toilet Organization
previously piloted a franchise model of Sanishops but is now operating in Kampong Chhnang
province only.
CLTS variations and practice

1 Global Sanitation Fund CR-SHIP: CLTS + Sanitation Marketing
GSF Cambodia Rural Sanitation and Hygiene Improvement Programme (CR-SHIP) phase 1 plans to
implement CLTS in 2,020 villages. Sanitation marketing projects are implemented by partners to
improve the availability and affordability of sanitation goods and services in the programme provinces.
By the end of December 2014, triggering occurred in 1,739 villages (up from 700 at the end of 2013),
resulting in a total of 445 villages with ODF status (up from 128 at the end of 2013).
2 SNVs Sustainable Sanitation and Hygiene For All (SSH4A)
This programme combines sanitation demand creation through CLTS with private sector development
for sanitation supply chain and finance, hygiene behavioural change communication, and improved
governance to scale up access to sanitation in the rural areas of Cambodia. The SSH4A programme
emphasizes the capacity building of partner agencies at provincial, district and commune levels to
plan, implement and monitor sanitation and hygiene interventions so that they can continue to
promote sanitation and hygiene for the long term. The first ODF commune was declared in Trapeang
Sala Khang Lech commune in Banteay Mas District in 2013. In this commune, previously only
25 per cent of households had access to a toilet and now 98 per cent own their own with 2 per cent
sharing. The programme now operates in six provinces.
3 Plan: Sanitation in Emergency Food Assistance Project-Additional Financing (EFAP-AF)
Plan supported CLTS, hygiene promotion and smart sanitation financing integrated in the ADB funded,
Ministry of Economy and Finance executed, Emergency Food Assistance Project-Additional Financing
(EFAP-AF) 2013-2015. This programme improves food security of poor and vulnerable people affected
by high food prices. The sanitation component involves CLTS triggering, with targeting of ID Poor 1
and 2 households for conditional cash transfers through an incentive payment of US$25 to buy
materials for latrines (50 per cent of the cost), if they have committed to sustainably applying the main
hygiene and sanitation messages (e.g., participation in CLTS events, availability of handwashing
facilities, availability of potable water, latrine pit dug) for the first 3-4 months of project
implementation. Financial incentives are delivered through a microfinance institution. Achievements
include 1,083 communities triggered and 22,859 ID Poor households having received incentives, of
which 61 per cent built latrines (53 per cent pour flush, 8 per cent dry pit).
4 USAID NOURISH Program
USAID is funding a five-year, US$16.3 million integrated nutrition, sanitation and hygiene project called
NOURISH to address the complex, multi-faceted causes of chronic malnutrition in Cambodia,
targeting rural areas in the poorest districts of Battambang, Siem Reap and Pursat provinces. The
programme, targeting ID Poor women and their children in the first 1,000 days of life, was launched in
late 2014 and is being led by Save the Children, with technical support from SNV. Sanitation activities
include product development and marketing through private sector promotion, as well as
strengthening the capacity of local partners to implement and create sanitation demand through CLTS
approaches.
CLTS scale
An estimated 1,49418 villages have claimed ODF, although not all have been verified and there is no
reliable source of data on this number. Guidelines to define ODF were introduced in 2014.
18 MRD 610; Plan/GSF 491; WV-C 207; SNV 186

ODF success rate
There is no centralized information on the number of villages triggered or ODF status, but estimates are
that 6,160 villages have been triggered with 1,494 ODF, giving a rate of 24 per cent achievement.
CLTS capacity
An estimated 260 facilitators have been trained to date. Most (70-80 per cent) trained facilitators are from
government (PDRD and DoRD), however only about 30-35 per cent of trained facilitators are still active.
Figures from the GSF programme suggests better retention of female facilitators. Only 18 per cent of
trained facilitators are women, yet women make up 32 per cent of active facilitators.
CLTS scorecard
ENABLING ENVIRONMENT
Policy 1 National Strategic Plan for 1 National Strategy for RWSSH For Sanitation: Use
CLTS in government policy RWSSH 2014-2025 (2013). sanitation behaviour change approaches (e.g., CLTS)
2 National Policy on Water and promote local markets to deliver sanitation products
Supply and Sanitation and services so that households buy, construct and use
(2003). latrines.
Principles: Each household should pay for its own toilet.
3 Government CLTS
Public finance is only used to create demand for better
guidelines and training
sanitation and hygiene behaviors, to facilitate the private
manual (2014).
sector in delivering sanitation services, and to improve
the capacity of the sub-national government to promote,
coordinate, monitor and report progress of sanitation
interventions. Direct hardware subsidies can only be used
in a targeted manner to support the poor.
2 2003 NPWSS: every person in rural communities will have
access to safe water supply and sanitation services by
2025.
3 National CLTS Guidelines (2014)
Strategy National Action Plan for 100 per cent of sanitation coverage by 2025, but no ODF
CLTS targets in government Rural Water Supply, targets in national strategy for RWSSH. A new National
strategies or development Sanitation and Hygiene Action Plan (under development) will include specific
plans (to be issued by the end of indicators and targets for ODF.
2015).
Leadership Ministry of Rural DRHC leading sanitation and CLTS direction. PDRD/DoRD
CLTS led by government Development. Department sets strategies, trains facilitators, implements, monitors
of Rural Health Care. and verifies. District government leadership not proactive,
although a pilot with functional transfer of sanitation
responsibilities to districts started mid-2015 (10 districts).
Finance Government support to The Department of Rural Health Care (DRHC) provides
CLTS financed by programmes. central support to CLTS and other rural sanitation
government programmes, with local implementation support provided
through provincial rural development offices (PDRD). Govern-
ment budget for sanitation has increased from US$320,000
in 2014 to US$580,000 in 2015, however this is generally for
hardware. DRHC is advocating the targeting of the poor and
greater allocation for software (e.g., CLTS) but this is yet to
happen. The budget for 2016 is expected to increase.
Coordination 1 WatSan Group. Implementers meet on technical issues but are generally
Mechanisms for stakeholder 2 Technical Working Group fragmented. No annual sector review although foreseen as
coordination on RWSSS (hosted by part of the NAP-process. TWG addresses high-level issues,
MRD, with participation such as National Action Plan development, decentralization
of other ministries and reform.
development partners).

IMPLEMENTATION AND SUSTAINABILITY
Integration 1 Sanitation marketing. 1 iDE sanitation marketing pilot used a shortened CLTS
CLTS integrated with other 2 Hardware subsidies. approach to create demand for the Easy Latrine. The GSF
approaches programme combines CLTS and sanitation marketing with
3 Nutrition. supply strengthening provided by its partners.
4 Early childhood. 2 Several programmes, notably the ADB RWSSP-2, are
planning to use CLTS to trigger demand for latrine
subsidies.
3 Several NGOs combine CLTS with nutrition interventions.
A new USAID NOURISH programme will integrate CLTS
and nutrition at scale.
4 Plan has been integrating Nutrition, Early Childhood
stimulation and WASH (iNEW) since 2013.
Triggering National CLTS Guidelines Facilitator training is standardized in so far as the National
Standardized facilitator Annex. 3 Facilitators Notes CLTS Guidelines provide a module for facilitators, including
training (2014). selection criteria for facilitators, description of duties and
community procedures. There is no centralized institution for
training of facilitators or professionalization of training.
Facilitator quality control National CLTS Guidelines Individual organizations check the quality of facilitators
Annex. 3 Facilitators Notes through a triggering performance checklist included in CLTS
(2014). guidelines. Only some implementers are providing sustained
capacity building of facilitators. Only 30 per cent of trained
facilitators are still active. There is no central register of
facilitators.
ODF National CLTS Guidelines New national guidelines on CLTS processes including ODF
Clear ODF criteria (2014). criteria: a) 100 per cent do not practice open defecation and
at least 85 per cent have access to functional, improved
latrines, and the remaining 15 per cent through shared
latrines; b) All households dispose of infant feces into owned
and shared latrines; c) There is no evidence of
human excreta in the village environment; and,
d) Communities have formulated and enforced informal or
formal actions against open defecation. Main implementers
of CLTS follow guidelines (government and NGOs).
Exceptions include ADB RWSSP and NGOs that do not
focus on collective outcomes.
Verification protocol National CLTS Guidelines Village ODF verification process clearly documented. The
(2014). verification process is expected to be done twice; once after
a village declares itself as ODF and the next after six months
of being ODF, although there is no evidence that this has
happened yet as the guidelines have only recently been
agreed. Verifiers include PDRD/DoRD, local authorities,
village focal point and programme staff. There is no
verification protocol for commune or district level ODF
achievements.
Post ODF support National CLTS Guidelines No formal process. Implementing partners informally follow
(2014). up with PDRD and commune/village leaders. Some partners,
such as SNV, formalize post ODF support by establishing
post ODF committees and developing strategies for the
continuation of ODF with reporting to commune level.
Technical support Low-cost affordable Limited choice of technology options, especially for the very
Availability of products and and package solution is poor. Physically challenging environments (e.g., flood areas
services widespread and available lack a cost effective solution).

through sanitation marketing
initiatives.

MONITORING AND EVALUATION
Monitoring In the past, DFID finance was used to establish a CLTS
Robust and regular database to track progress in Cambodia, but this database
monitoring of ODF is no longer used. Manual monitoring of ODF criteria occurs
achievements on a project or programme level, but each implementer
uses different systems. There is no coordinated, national
monitoring of ODF status. A National WASH Management
Information System is under development.
Post ODF monitoring of Not systematic. National CLTS guidelines do not address
quality and sustainability how and when to follow up post ODF: Periodic check
on the sustainability of ODF status needs to be agreed
and followed in the programme. Slippage is not routinely
monitored. There is no procedure for a community to lose its
ODF status.
Evaluations and WatSan Group meetings. Lessons are shared through WatSan Group meetings,
knowledge sharing quarterly and annual programme meetings. Several studies
Evaluations, reviews and by implementing partners contribute to sector knowledge,
learning e.g., Plans: Testing CLTS Approaches for Scalability:
Cambodia (2014).
Information on costs and Unit costs and resource calculations are not centrally
resources for CLTS available.
Most significant changes since 2012

1 National CLTS guidelines Previously there was no official guide for the CLTS implementation process. The National
Guidelines have resulted in a common sanctioned approach which is clear and easy for
implementers to follow. The Cambodian definition of ODF has been agreed and the verification
process is clear. This has brought unity and conformity to the sector.
2 Improved facilitation Facilitation has improved through the National CLTS Guidelines selection criteria for facilitators
and through clear statement of duties. A core group of master trainers at the national lever has
developed their capacity and skills over time. The training of facilitators is more thorough,
resulting in improved triggering at community level.
3 Large programmes scale Major programmes, such as the GSF C-SHIP, have boosted CLTS implementation and driven
up CLTS evolution in Cambodia. The number of national NGOs with CLTS experience has also increased.
4 Increased access to Coverage of sanitation and the number of ODF villages has increased significantly in the last
durable and affordable three years. Much of this increase is in durable and affordable pour flush toilets.
sanitation products
5 Change in thinking CLTS is seen as one element in a sustainable, sanitation solution and there is wider thinking
about linking LCTS with the need to improve the supply chain, as well as behaviour change
communication efforts and the use of pro-poor support mechanisms. National BCC guidelines
are in development which recognize various approaches and methods, including CLTS, as one to
address collective change.
Lessons learned
1 Households prefer pour The sanitation ladder concept is not applicable in Cambodia. Households will frequently delay
flush toilets purchase until they have their preferred pour flush latrine. This can delay the achievements of
ODF but can lead to improved sustainability of sanitation behaviour.
2 Triggering Triggers that work best to mobilize the community include: disgust, shame, self esteem, desire
for good health, privacy and convenience. Triggering with children appears effective, resulting in
children urging their parents to build a toilet.
3 District based sanitation A district-wide, local government-led approach is more effective and sustainable in comparison
is effective and the role with targeted support only for a few selected poor communes or villages. Partnership with local
of district administrations authorities and market suppliers increases government capacity to steer and scale up sanitation
for rural sanitation should initiatives, and builds local momentum to reach all with improved sanitation. Commitment and
be enhanced leadership of the provincial and district authorities is important, but can only be achieved when
the programme covers a larger area. SNVs SSH4A approach has led to stronger commitment
and ownership in all target districts. In 2013, after introducing the results based sanitation and
hygiene planning at district level, the impact and results were more than triple those from the
previous year. To strengthen the district-wide approach, a gradual transfer of rural sanitation man-
date to district administrations could help to scale-up government-led service delivery.

Lessons learned (continued)
4 Local context is important CLTS demand creation approaches need to accommodate local solutions to local problems, and
the solutions depend upon a clear understanding on the sanitation situation and the
communitys socio-cultural norms, values and motivations. One size does not fit all.
5 CLTS and sanitation If CLTS and sanitation marketing are integrated, the achievements can be quick and
marketing is a powerful sustainability can be improved.
combination
6 Share best practices Learning exchanges between government officials at commune, district and provincial levels
through peer to peer accelerate rural sanitation and hygiene achievements. Joint progress review meetings and
learning to accelerate visits between the districts and provinces create healthy competition for increased sanitation
progress coverage.
7 Diffusion Neighbouring, non-triggered villages copy sanitation improvements from triggered communities.
8 Promotion Publicity on national days/international days (e.g., global handwashing day) is effective at
spreading information to communities, including about sanitation.
CLTS weaknesses and bottlenecks

1 ODF not a key indicator National level targets and monitoring focuses on sanitation coverage, not ODF achievements.
2 Continued use of Acceleration of progress and effective scaling up of sanitation is undermined by competing or
subsidies contradictory approaches in the same location, particularly the use of hardware subsidies that
are not employed in a targeted manner for the poor and delivered in a smart way. There is more
consensus in the sector that a pro-poor mechanism is needed and a guideline will be drafted
in 2015.
3 Lack of national There is no central place for monitoring and tracking ODF statuses of villages, therefore it is
monitoring system difficult to obtain a national picture of the progress of CLTS and ODF status or to identify lagging
areas within the country.
4 No post-ODF monitoring No procedure for monitoring sustainability and slippage of previously verified ODF
communities. Post ODF monitoring is uneven and not formalized.
5 Limited latrine There are few latrine options available for households. Affordable technology solutions are yet to
technologies be developed for challenging environments i.e. flooding areas, floating areas, mountains.
CLTS opportunities over the next 3-5 years

1 National Action Plan A National Action Plan to be developed in 2015 will set ODF targets and guide the allocation of
government funds, and mobilize funds from other donors to support sanitation. The NAP will be
an umbrella to mobilize a common approach.
2 Management Information An MIS (currently under development) will monitor and capture national progress on ODF
System achievements. The MIS will be trialled in provinces where GSF is operating. Up until now, CLTS
has relied on anecdotal information with market based programmes having much better
quantitative dates (e.g., sales).
3 Increased funding Continued support of donors, such as the expansion of GSF programmes to five new provinces,
and more funds expected from the Government.
4 Improved coordination More coordination is necessary, particularly at district level, in order to create a synergy and
reach the sanitation vision. The existing good collaboration between government and partners
can further support governments in developing sanitation in the future. MRD has submitted their
functional review document to the Government in which rural sanitation is a proposed function
for transfer to district administrations. Piloting of this transfer from 2015-2016 in 10 districts will
be foreseen before such transfers would be enacted nationally.

5 Sanitation integrated with Nutrition is receiving increasing attention and links with sanitation are much better understood
other approaches e.g., by policy makers. The US-AID NOURISH programme is anticipated to provide learning on links
nutrition and early between sanitation and nutrition and how to integrate them.
childhood Plan Cambodia has been implementing iNEW for integrating WASH with nutrition and early
childhood, and has developed iNEW tools using positive approaches.
6 Cost norms A costing exercise to gather unit costs for implementation of CLTS by different partners could
contribute to accurate scaling up and targeting costs for the National Action Plan. Cambodia has
a sufficient history of CLTS implementation to provide this information. Plan estimates costs per
village for triggering and post-triggering follow up visits to be around US$1,200 to US$1,500,
which includes ODF status and staffing costs for implementing partners.

CHINA
CHINA: Country CLTS overview
Rural sanitation
2012 2015
100 2
Status and CLTS date of introduction 2011 Not yet 5
scale
90
CLTS coverage: major organizations 2 2 80 31

Villages triggered (number) 0 50 70 51
ODF villages (number) 0 31
3
Capacity developed (trained facilitators) 53 210 60
Enabling CLTS in government policy No No

50
CLTS targets in government plans No Some
CLTS financed by government No No 9
40
CLTS integrated with other approaches No No
CLTS sustainable monitoring No No 64
30
Effectiveness ODF success rate 0% %
20 35
Scale of rural sanitation challenge
10
2012
Open defecation 2% 3,770,351 12,442,160 13,483,000 2000 2015
Unimproved sanitation facilities 31% 58,440,447 192,853,475 188,762,000 Open defecation
Shared sanitation facilities 3% 5,655,527 18,663,240 94,381,000 Unimproved sanitation

Total without improved sanitation 36% 67,866,326 223,958,875 facilities
Shared sanitation

The JMP estimate for China suggests a rise in improved sanitation coverage in rural areas from
35 per cent in 2000 to 64 per cent in 2015. A significant proportion of the rural population in China
continue to use unimproved sanitation facilities, but this has been reduced from 51 per cent to
31 per cent (296 million people down to 223 million), with the open defecation rate estimated at only
2 per cent in rural areas. Nevertheless, the huge population means that more than 3.7 million rural
households practice open defecation and a further 64 million rural households use either unimproved or
shared sanitation facilities.
Open defecation is limited in rural areas of China because of the long history of using human excreta as
organic fertilizer in farming. It has been reported that 93 per cent of rural human excreta is used as
organic fertilizer, with most households using some form of latrine to collect the excreta. However,
some research suggests that the use of human excreta is now practiced by only around 30 per cent of
the population.

First introduced by Plan China in Shaanxi province in 2005, however the approach was not adopted after
the initial pilots due to over-riding government and NGO preference for latrine subsidies. No further
progress was made until 2011, when UNICEF and its government counterparts organized another
training workshop in Jilin province to build capacity for a Community Approaches to Total Sanitation

(CATS) programme in 50 villages across five provinces (out of 33 provinces). UNICEF is continuing to
support CLTS in five provinces, but within three of these provinces the approach has been extended to
other villages.
The project counties were selected based on many conditions such as geographical focus (as well as
linking with health and nutrition projects), economic conditions, ethnic groups, willingness of local
partners, coverage of improved sanitation, etc.
MAJOR EXCEPTIONS
Subsidy programmes HEALTH
Government and most NPHCC
NGOs UNICEF
The China Rural Water Supply Technical Center (CRWSTC), under the China Center of Disease Control
(CDC), was entrusted by the National Patriotic Health Campaign Committee Office (NPHCCO) to be the
line agency at the central level in implementing CATS projects in cooperation with UNICEF. In the five
provinces and five counties, county PHCCOs and/or county CDCs are responsible for the routine
implementation of CATS, including setting targets, planning, coordination, triggering, technical support,
monitoring, verification, documentation, diffusion, etc.
CLTS scale
An estimated 31 communities have been certified as ODF under UNICEFs CATS programme.
ODF success rate

Triggering is small scale with the UNICEF project responsible for triggering of 50 project villages.
The water/food-flies-faeces tool works best in China. Farmers are disgusted at eating faeces and have
a desire for good health. Convenience is also an important trigger.
Time from triggering to ODF status varies, with some communities rapidly achieving ODF when they
integrate the national sanitation programme for latrine coverage, whilst in other villages, where there
is no external programme supporting latrine building, there has been inaction.
CLTS capacity
An estimated 210 facilitators from CRWSTC, provincial and county CDCs have been trained on CATS
methodologies as facilitators. Out of the 210 trained, only 10 are still active in implementing the
demonstration project, however the remainder integrate triggering skills into their daily work in sanitation
promotion and health education.

CLTS scorecard
Policy 1 2003 Hygienic standard 1 Requirements of sanitary latrines: walls, roofs, leak-proof
CLTS in government policy for rural household tanks, airtight covers, clean, free from flies and maggots,
latrines (GB19379-2003). odourless, and harmless treatment of faeces. National
2 Rebuilding Sanitary Patriotic Health Campaign Committee (NPHCC) promotes
Toilets in Rural Areas six types of harmless sanitary latrine. The Government
national programme 2009. of China has set very high standards for sanitary latrines,
hence the cost is high.
2 In 2009, the central government listed Rebuilding
sanitary toilets in rural areas as one of six national
important public health services programmes. In the
same year, the subsidy fund was allocated at a number
of 1.56 billion RMB to support 4.11 million households to
rebuild harmless sanitary toilets nationwide.
3 Collective sanitation is set as a principle in the sanitation
authoritys (NPHCCO) policy on rural sanitation
movements. It requests for whole village improvement,
however, CLTS triggering methodology is not officially
used yet as a nationwide approach, which is linked to the
governments financing mechanism.
Strategy 1 Healthy China by the year 1 Medium and long-term plan for the health sector until
CLTS targets in government 2020. 2020.
strategies or development 2 12th Five-Year-Plan, 2 12th Five Year Plan aims to have 75 per cent sanitary
plans 2011- 2015. latrine coverage in rural areas by 2015.
3 Some provincial 3 CATS has been accepted in some provinces, e.g., Jiangsu
acceptance of the province, and in some project counties as a sanitation
strategy. promotion approach.
Leadership National Patriotic Health The China Rural Water Supply Technical Center
CLTS led by government Campaign Committee Office (CRWSTC), under the China Center of Disease Control
(NPHCCO). (CDC), was entrusted by the National Patriotic Health
China Rural Water Supply Campaign Committee Office (NPHCCO) to be the line
Technical Center (CRWSTC) agency at the central level to implement CATS projects in
under the China Center of cooperation with UNICEF. In the five provinces and five
Disease Control (CDC). counties, county PHCCOs and/or county CDCs are
responsible for the routine implementation of CATS,
however the government heavily relies on UNICEF to lead
CATS promotion.
Finance No finance directly for CLTS. No direct finance of CLTS activities from central
CLTS financed by government, but local government provides subsidies for
government sanitation hardware. Water, sanitation and hygiene are three
out of the 66 elements of healthy behaviour promoted by
the government-financed health education programme.
Coordination Limited. Project level coordination only.
Mechanisms for stakeholder
coordination

Integration Health sector. CATS triggering methodology and key messages are
CLTS integrated with other Poverty reduction. integrated in handwashing, WASH in schools and WASH
approaches in township hospital projects. The CATS approach has also
been introduced to government poverty reduction projects,
government local health institution director training and

university student classes majoring in health education and
journalist training. It is now being integrated in joint
sanitation and nutrition projects.
Triggering CLTS guidelines. Kamal Kars triggering guideline has been translated into
Standardized facilitator Chinese and has been used in the pilot project.
training
Facilitator quality control No formal monitoring system. Feedback at project annual

planning and review meetings shows that facilitators do not
purely use CATS triggering skills when they work in the field,
and most local project staff integrate one or several tools of
triggering into their routine health education work on sanita-
tion promotion. There is no central register of facilitators.

IMPLEMENTATION AND SUSTAINABILITY (continued)
ODF No standards from government, but UNICEFs Three star
Clear ODF criteria ODF standard is adopted in project counties.
The standards four indicators are:
1 sanitary latrines/covered pit latrines;
2 safe disposal of childrens faeces;
3 no faeces in public places; and
4 handwashing facilities with soap/liquid soap in/nearby
latrine/room/yard.
Once the village reaches level one it can request for
nomination of ODF.
One star ODF village: no sanitary latrine but all
households cover their pit latrines. Plus all other hygienic
behaviours adopted (2, 3, 4).
Two star ODF village: some households having built
and used sanitary latrines, while the rest cover their pit
latrines. Plus all other hygienic behaviours adopted
(2, 3, 4).
Three star ODF village: all households having built and
used sanitary latrines. Plus all other hygienic behaviours
adopted (2, 3, 4).
Verification protocol No national protocol. In UNICEFs project counties, the

community submits request to County PHCCO (local
implementation management office) through local township
government for verification of ODF. The County PHCCO then
asks the county Center for Disease Control to do
verification (at least 10 per cent of the households) within
one month of the request. Once verified, County PHCCO
awards an ODF title to the community.
Post ODF support No national guidelines but principles only. UNICEF has
developed a clear project protocol for support in project
counties. After three months of ODF declaration, the County
PHCCO entrusts the County CDC to conduct monitoring
of the village. If issues are identified, the village is asked
to improve within a given period. One year later, the same
monitoring will be conducted by the County CDC. At least
10 per cent of the households should be visited. If more
than 20 per cent of the visited households have faeces
exposure or there is faeces in public places, the title of ODF
village will be removed.
Technical support Government support to Through sanitation marketing forums and government
Availability of products and supply chain. sanitation programmes, private suppliers and local
services government implementers interact and build a chain for
the provision of supplies. Technical information is usually
provided as part of the CATS promotion process. Almost all
provinces have developed and printed advocacy materials
including technical options and 3D-dimensions of drawings
for sanitation promotion, which are posted on the walls in
the villages before the triggering. Lectures are also given to
beneficiaries during or after the triggering.
Monitoring 1 National Bureau of 1 NBS conducts annual household surveys in accordance

Robust and regular Statistics on sanitation with the JMP sanitation definitions. The government
monitoring of ODF coverage. routinely monitors environmental sanitation risk and
achievements 2 Pilot ODF monitoring only. sanitation coverage.
2 Under the pilot, local government is requested to verify
ODF before nomination and conduct monitoring
periodically after certification. County CDCs are
responsible for monitoring but this is only at project
county level and is recorded manually.
Post ODF monitoring of Not systematic monitoring and no formal procedures,
quality and sustainability but quality of sanitation is good and slippage is assumed to
be low.

MONITORING AND EVALUATION (continued)
Evaluations and No evaluations of CLTS yet. Lessons learned are shared
knowledge sharing through joint meetings, communication, or input/comments
Evaluations, reviews and for government documents, etc.
learning
Information on costs and No data on unit costs and resources for CLTS.
resources for CLTS

1 Increased acceptance of Government officers like the concept of ODF. CATS triggering tools are now well accepted by
CLTS local sanitation practitioners in UNICEF project areas. In the new State Councils paper on
patriotic health, the community total sanitation is set as a principle.
2 Integration in other The CLTS concept and the triggering methodology have been applied to WASH in schools and in
settings local health facilities. This is currently on a limited scale but has the potential for wider
integration.
Lessons learned
1 Better results when Without integrating into government programmes, such as health and schools, it is difficult to
integrated in to achieve scale up of ODF.
government programmes
2 Attitude of government The mindset of government officials in-charge affects progress in scaling up. Government
officials affects scaling up officials involved in project implementation are positive in scaling up CATS as they properly
understand how CATS works. Government officials in non-project areas are reluctant to use
CATS procedures to promote sanitation as CATS is thought to be time-consuming, complex,
not necessary, etc. This suggests that more exposure to CATS/CLTS is needed outside of project
areas. Government managers in the financing sector would like to finance the hardware compo-
nent of the sanitation promotion rather than financing software.
3 New culture and social New culture and social norms are effective. Some of the communities set village regulations and
norms are important in social norms to commit to ODF and clean/tidy village environment, etc. In some counties, sev-
CATS promotion eral households are selected as clean model households to show other villagers how to improve
household sanitation.
4 Coordination among Many sectors or departments implement various programmes which can integrate sanitation
government departments into planning, however sanitation may not be their mandate.

1 ODF not a key indicator No national ODF criteria.
2 Government subsidy The government has been subsidizing the construction of household latrines since 2003,
programme especially after 2009, which has created a tendency among local villagers to wait for the
government subsidy programme to come and has created dependency on government
financing.
3 Lack of government Government needs to take the lead for scaling-up by planning for the CLTS approach with
leadership in scaling up targets set for different areas, adequate working budgets and trained staff as facilitators to
conduct triggering. The Government tends to push for total sanitation in a community through
various programmes. CATS triggering needs to be strengthened.
4 Unaffordability of high The Government sanitation standard adheres to strict technical specifications for toilet
standard latrines for construction, making the cost for latrine construction high. This is a challenge for rural poor
some areas and for some households to have the money to reach the required latrine standard. Hygienic standards for
households rural household latrines requires that all latrines have seepage-free and leak-proof tanks or pits,
which greatly constrains the construction of simple pit latrines made from local materials.
5 Rural village life no longer A challenge to the collective action approach of CLTS/CATS is that the traditional set up of a
cohesive village no longer exists, with villagers working in their own fields and seldom undertaking
collective activities, or contributing free labour for public works. Families leaving rural villages
to work as urban migrant workers only come back for a short time during the Spring Festival,
which affects village cohesion.

1 Make ODF an indicator Integration of ODF as an indicator in government monitoring systems; adoption of ODF as an
in national planning and indicator for assessment of national programmes.
monitoring
2 Wider integration Integrate CATS with MCH and nutrition programmes to maximize the CATS impact.
Integrate CATS into rural community development programmes through many authorities that
are not mainstream sanitation actors, but who can help effect change.

DPR KOREA
DPR KOREA: Country CLTS overview
Rural sanitation
2012 2015
100
Status and CLTS date of introduction Not yet Not yet
scale
CLTS spread: % of country
90
CLTS in urban areas 24
CLTS coverage: major organizations 80 43

OD population rural (2010 and 2015, mill) 0m 0m
3
Villages triggered (number) 70
ODF villages (number)
Capacity developed (trained facilitators) 60
2
50
CLTS financed by government No No
40
73
CLTS sustainable monitoring No No
30 55
Effectiveness ODF success rate
20
10
2012
Open defecation 0% 0 0 0 2000 2015
Unimproved sanitation facilities 24% 576,118 2,362,084 2,518,400 Open defecation

Total without improved sanitation 27% 648,133 2,657,344 2,809,000 facilities
Shared sanitation

The JMP estimate suggests a rapid rise in improved sanitation coverage in rural areas from a 55 per cent
in 1995 to 73 per cent in 2015. A significant proportion of the rural population in DRP Korea continue to
use unimproved sanitation facilities, but this has been reduced from 43 per cent to 24 per cent, with
no open defecation reported in rural areas. Nearly 650,000 rural households use unimproved or shared
sanitation facilities.


CLTS has not been introduced in DPR Korea. Very low rates of open defecation meant that few
stakeholders recognized rural sanitation as an important issue. There is now increasing recognition of the
relatively high proportion of unimproved sanitation facilities and of the health problems caused by the
widespread use of untreated human excreta in agriculture.
Institutional mapping
There are relatively few development partners working in the rural sanitation sector: UNICEF, SDC, IFRC,
Save the Children and CONCERN.

Key sanitation issues
The use of human excreta for fertilizer is highly prevalent some estimates suggest it is practiced by up
to 80 per cent of rural households, with systematic excreta collection and use in many rural communes.
However, it remains a sensitive cultural and socio-political issue: the practice is sometimes linked to
shortages of chemical fertilizers and there is little awareness of the health risks related to the handling
and application of untreated human excreta. In many areas, shallow latrine pits are utilized, sometimes
using earthen pots to collect urine and faeces, which only provide one or two months storage, thus
requiring regular emptying without sufficient composting time to kill off pathogens.
Enabling environment
UNICEF has been raising awareness about the risks of existing sanitation practices and the benefits of
investment in sanitation improvement among local authorities and the rural populations. UNICEF
supported the development of rural sanitation guidelines based around safe management of human
excreta that was launched by the Ministry of City Management (MoCM), the governments lead WASH
agency, in 2011, after a long period of advocacy and negotiation. The guidelines, which provide
straightforward advice on the risks associated with untreated human excreta and outlines some low-cost,
appropriate treatment options, are now being disseminated nationally to local governments, community
leaders and farmers.
In 2014, UNICEF facilitated a study visit to China to assess the possibilities of improvised sanitation
design. The study visit was followed by an in-country technical workshop where several design options
were considered. The MoCM selected the sanitary double pit latrine for demonstration and adaptation to
the DPRK context as the highest standard for rural sanitation that will ensure safe latrines as well as safe
handling of excreta (sludge) used as manure in agriculture. The model will be piloted in the three
districts under the WASH for All Initiative and demonstrated in all UNICEF focus counties and districts.
The piloting will include developing and adapting the harmless sanitary double urn latrine model using
local materials and technology, which will be introduced in all counties. A training workshop was
conducted with technical assistance from UNICEF China on latrine design and strategy development for
improving household and institutional sanitation. UNICEF will support the preparation of training modules
and technical manuals.
The MoCM has recently started an inter-ministerial consultative meeting with other agencies active
in sanitation and hygiene. This collaboration of sector ministries in sanitation and hygiene is under the
WASH for All Initiative introduced with UNICEF. This is part of the expansion of partnerships for
implementing hygiene and sanitation promotion. With an emerging consensus among government
ministries, departments and agencies, with various roles in sanitation and hygiene to prioritize the
development of a national action plan for the improvement of latrines in the rural areas, the timeframe for
updating the policies was set at December 2015.
Opportunities
Potential for CLTS

UNICEF hopes that the pilot improved sanitation for all project will demonstrate that it is possible
to achieve 100 per cent ODF and improved sanitation status without compromising the use of treated
excreta as a valuable fertilizer and soil conditioner. Once the Government is convinced that
community-wide outcomes are possible, then it is hoped that CLTS can be introduced as a tool for
scaling up sustainable behaviour change and sanitation improvement across the country.
Opportunities for integrating CLTS with efforts to tackle poor nutrition are possible. According to the 2012
National Nutrition Survey, 28 per cent and 4 per cent of children under five years suffer from
chronic malnutrition (stunting) and acute malnutrition (wasting), respectively.

1 Increased interest of Growing awareness of government on the need to improve fecal sludge management. This is
government evident through increased collaboration and formal consultations between agencies, as well as
support in a UNICEF pilot for improving latrine models.

INDONESIA

INDONESIA: Country CLTS overview
Rural sanitation
2012 2015
100
scale
90
CLTS in urban areas No Yes
29
Villages triggered (number) 7,325 24,955 70
ODF villages (number) 1,279 4,419 12
Capacity developed (trained facilitators) 530 >2,000 60

50 17 12
CLTS targets in government plans Yes Yes
CLTS financed by government Yes Yes
40 8
CLTS integrated with other approaches Yes Yes
CLTS sustainable monitoring Yes Yes
30
47
20
34
10
2012
Open defecation 29% 8,575,792 34,303,167 38,322,880 2000 2015

Shared sanitation

The JMP estimates suggest an increase in improved sanitation coverage in rural areas from 34 per cent
in 2000 to 47 per cent in 2015. A further 24 per cent of the rural population use either shared sanitation
facilities or unimproved facilities. Open defecation is estimated to be 29 per cent, which suggests that
more than 8 million rural households (34 million people) do not use any form of sanitation facility.
However, according to JMP data, since 2012 approximately 4 million rural people have stopped open def-
ecation, and since 1990 approximately 21 million rural people have gained access to sanitation.


Introduced by WSP in 2005, CLTS had reached 54 districts (kabupaten) by 2007 (13 per cent of the total
number of Districts); by 2012 it spread to 234 out of 405 districts in Indonesia (58 per cent nationally)
including 32 out of the 33 provinces (97 per cent of provinces), and as of mid 2015 it has spread to
492 out of 514 rural and urban districts across all 34 provinces (reference: STBM http://stbm-indonesia.
org/monev/).

International Bilateral Multi-lateral

National NGOs NGOs Private sector programmes agencies Government
YDD Speak Adaro

Plan USAID Public
UNICEF
IU-WASH Works
YMP
CD Unilever
YPCII Bethesda SAVE SNV
WSP
HAR Dutch
Yayasan Embassy Health
FA WIN WVI
Rumsram MoH
devt Simavi
TP
Kemen
Australia
kes
DFAT World Bank
PAMSIMAS BAPP
MAJOR EXCEPTIONS ENAS
Subsidy programmes
None
Since 2008 CLTS has been implemented through a National Strategy for Community-Based Total
Sanitation and Hygiene Sanitasi Total Berbasis Masyarakat, STBM which includes five pillars:
1 Open defecation free (ODF) communities;
2 Hand washing with soap at critical moments;
3 Household water treatment and safe storage of water and food;
4 Solid waste management; and
5 Liquid waste management.
The programme advocates a subsidy-free approach to sanitation and generally concentrates on achieving
ODF villages with implementation at the district and village levels. Implementation is highly decentralized
and dependent on district mayor support to approve funding for STBM activities, resulting in uneven
implementation across the country. At central government level, a secretariat in the Ministry of Health
has been set up to assist the implementation and acceleration of the STBM programme. This is key for
the scale up and acceleration of STBM at the nationwide level, however the STBM secretariat
requires continued assistance to build capacity and coordinate implementation. There is a need to further
strengthen strategy at central levels on how to scale up nationally and how to improve consistency,
quality and sustainability of sanitarian training, policy setting and monitoring with follow up.
Since 2012, the private sector is a new entrant with organizations such as the mining company Adaro
implementing CLTS to improve sanitation in its operational areas in South Kalimantan, done through its
corporate social responsibility programme.
Major support programmes include:

World Bank PAMSIMAS Program: The Ministry of Public Works (PU) is the main implementation agen-
cy for PAMSIMAS, with the sanitation component being the responsibility of Ministry of Health. PAM-
SIMAS is currently in its second iteration and, since 2013/2014, implements the programme through
existing government structures, such as sanitarian and health cadres to promote
unsubsidized sanitation and ODF villages. According to PAMSIMAS staff, this approach has been more
effective than externally employed health facilitators and builds the capacity of the health
network in the long term.19 PAMSIMAS is operating in 280 districts in the country. A third phase is
being planned (2016-2019) to respond to the goal of universal access to water and sanitation. Phase 3
will increase PAMSIMAS to cover 5,000 more villages in 110 districts throughout 15 provinces.
19 World Bank (2015) Interim Implementation Completion and Results Report for Indonesia PAMSIMAS Project.

UNICEF: Direct support to national and sub-national government on the implementation of CLTS/
STBM. In partnership with the Government and civil society, learning is being derived from six
districts with 12 additional indirect districts in the provinces of South Sulawesi, Nusa Tenggara Timur
and Papua (including West Papua). UNICEF provides technical assistance and funding to its local
planning office (Bappeda) for a full time provincial coordinator, and supports the training of sanitarians
on implementation at district level. Replication and scaling up to other districts and sub-districts is
achieved through advocating for the prioritization of STBM programmes and capacity building for local
government staff, including planning and budgeting skills, coordination and monitoring. UNICEF is
also supporting policy development, clearer roadmap creation for planning and strategizing, capacity
building, and advocacy at the national level.
World Bank Water and Sanitation Program (WSP): Support comes in the form of technical assistance
to the national STBM secretariat and provincial level technical assistance for CLTS implementation
in the provinces of East Java, West Java, Central Java, Nusa Tenggara Barat and Bali. This includes
supporting PAMSIMAS in these provinces. At central level, support includes improving monitoring,
training and capacity building of sanitarians, and advocacy.
Dutch Sanitation, Hygiene and Water Program for Eastern Indonesia (SHAW): SHAW was launched
in 2010 and ended in December 2014. This programme claims to be the only civil society programme
in Indonesia implementing all five STBM pillars simultaneously. The programme was implemented
by a Dutch NGO, Simavi, and five Indonesian/international NGOs. At its conclusion, it reached 1,042
villages, with 489 villages being verified as achieving all 5 pillars (including ODF), and an overall access
to sanitation of 88 per cent. 40 sub-districts were also declared STBM. SHAW was working in nine
districts across three provinces: Nusa Tenggara Timur, Nusa Tenggara Barat and Papua, as well as the
national level.

None

1 USAID IU-WASH programme: urban CLTS with some modifications (linking to citywide
sanitation strategies and utility projects)
The USAID IU-WASH programme is working with local water utilities (PDAMs), local technical waste
water implementation units (UPTD PAL) and other sector stakeholders on urban CLTS. Indonesia
Urban Water, Sanitation and Hygiene (IUWASH) is a five year (2011-2016) development programme
funded by the US Agency for International Development (USAID). IUWASHs sanitation component
aims to create access to improved sanitation facilities and services for 250,000 people (50,000
families) in 54 cities/districts spread within the IUWASH regions of North Sumatra, West Java/Banten/
DKI, Central Java, East Java and South Sulawesi/East Indonesia. CLTS-type triggering is included as
part of demand creation strategies for household sanitation improvements.
2 Community engagement and Village empowerment, NTT
UNICEF is working with the NTT Province to integrate STBM into Desa/Kelurahan Mandiri
(Empowered Village) called ANGGUR MERAH programme. The Anggur Merah is funded from
province budgets, allocating IDR 300 million per villages and inclues IDR 50 million for housing direct
support for poor families. Other openings in this province include stronger linkages with nutrition,
especially to support both WASH infrastructure in health facilities and communities through nutritional
platforms (e.g. nutrition messages with a strong handwashing component), and improving how health
staff integrate these messages.
CLTS scale
As of mid 2015, the government monitoring system shows that 24,955 villages in Indonesia have been
triggered (out of 80,276) with 4,419 verified as ODF and a further 1,784 villages claiming ODF. Indonesia
has a moderate ODF success rate: 18 per cent of triggered villages have been verified ODF, with up to 25
per cent if claimed and verified villages are counted.
CLTS capacity
Very large numbers of CLTS facilitators have been trained in Indonesia by both development agencies
and, more recently, through the Ministry of Health training course for sanitarians, with replication at
provincial levels.

CLTS scorecard
Policy National Strategy for STBM: No hardware subsidy for household toilets.
CLTS in government policy Community-Based Total The STBM sets a clear no-subsidy policy for all rural
Sanitation (STBM) 2008. sanitation programmes in Indonesia.
Strategy 2010-2014 National RPJMN-2: the previous 5-year development plan set the
CLTS targets in government Medium-Term Development target of 100 per cent ODF villages nationally by 2014.
strategies or development Plan (RPJMN-2). New RPJMN-3 2015-2019 has the goal of universal access
plans 2015-2019 National by 2019, however the interpretation of this is unclear.
Medium-Term Development In response to this new policy, the Government has
Plan (RPJMN3). proposed to scale up the PAMSIMAS Project to about 5,000
villages nationwide, starting from the year 2016 to 2019.
Leadership 1 National STBM is a government led programme under the Ministry of

CLTS led by government 2 Provincial Health. The Government has issued key supporting
documents to guide implementation at subnational level:
Universal access of drinking water and sanitation in
RPJMN (100-0-100)
President Regulation No. 185 Tahun 2014: on acceleration
of provision of drinking water and sanitation
Village Minister Regulation No. 5 Tahun 2015: on Priority of
Village Fund Utilization
Circular letter from Health Minister to Governor and Bupa-
ti No. 184/ 2015 on Funding for Preventive Health Services
Advocacy letter of Minister of Health to village leaders No.
323/ 2015 on STBM implementation.
There is evidence of regulations on STBM implementation at
provincial and district level governments in some locations.
While the structure for government leadership exists, it is
not carried through consistently across the country and
depends on the local priority given to sanitation.
Finance 1 GOI 1 MoH funds through provincial health offices and district
CLTS financed by 2 World Bank PAMSIMAS health offices to conduct trainings, triggering (including
government pre and post triggering) activities and SMS based
3 Village programme monitoring. Some district health offices have allocated
some of their district funds to finance CLTS/STBM
activities.
2 PAMSIMAS: Loan of funds to GOI for implementation,
including CLTS.
3 The newly elected government is proposing direct
funding to villages of US$100,000 annually for all local
development, including some provisions for sanitation.
Villages may have limited capacity to implement and
monitor.
Coordination National and provincial Coordination at national levels through Pokja AMPL.
Mechanisms for stakeholder Pokja. At province and district levels, governments established
coordination Kelompok Kerja (Pokja) AMPL or WASH working groups,
however these are very active in some locations and
not active in others, creating uneven coordination across
the country.

Integration 1 Sanitation marketing 1 WSP pioneered Total Sanitation and Sanitation Marketing
CLTS integrated with other 2 Empowered Village in all 29 districts of East Java, and now forms of STBM
approaches and certain aspects of sanitation marketing have been
3 Urban adopted by MoH.
2 UNICEF is working with NTT Province Bappeda to
strengthen community engagement via linking STBM
into Desa/Kelurahan Mandiri (Empowered Village) called
the ANGGUR MERAH programme. The Anggur Merah is
funded by the province budgets, allocating IDR 300
million per village, including IDR 50 million for housing
direct support for poor families, as well as linkages to
broader community interventions.
3 CLTS integrated in USAID IUWASH urban sanitation
programmes.

Triggering MoH Training Module. MoH has developed and launched a Training of Trainer and
Standardized facilitator Training of Facilitator STBM module in 2013, which is
training followed by all implementers. Full training package for
sanitarians is five days. STBM is already included in the
curricula of Poltekes (Health Polytechnic) for health
environmental studies.
Facilitator quality control Checking of facilitators and UNICEF and NGOs conduct self-evaluation of STBM
sanitarians. facilitation principles and skills amongst facilitators.
DHO evaluates the quality of CLTS triggering done by
sanitarians. WSP is developing, with MoH, an accreditation
system for sanitarians which would incentivize and reward
sanitarians, e.g. status and salary improvements. Online
skills development and resources are also available. Skill
levels of sanitarians vary widely.
Since 2013, MoH connects the STBM capacity building
programme to the Ministrys human resource development
schemes through accredited training, individual government
officer performance credit mechanisms, e-learning, and by
including it into the health polytechnic schools curricula.
ODF MoH STBM ODF guidelines National MoH guidelines on ODF include three criteria:
Clear ODF criteria (these are currently being 1 No OD practices found in the community areas.
revised and strengthened
and will contain improved 2 Everyone has access to improved sanitation facilities.
direction on verification of all 3 There is a social control/norm to ensure the sustainability
5 pillars of STBM). of ODF.
Some additional local criteria (e.g. sanitation facilities) must
be available in every public building (e.g. community health
center, village office and schools). ODF declarations for
100 per cent of households applying for ODF and STBM
declarations for communities that adopt all 5 pillars of STBM
should also be available.
Verification protocol MoH STBM verification Clear process in MoH verification guidelines (currently being
guidelines revised and strengthened):
1 Villages claim ODF request verifications from Community
Health Center (CHC) at sub-district level.
2 The CHC reports to DHO and arranges verification.
3 DHO team (consisting of 2-3 people) visits the claimed
villages for verification. Team can include members from
other ODF communities and STBM sub-district team.
4 Result of ODF verification is shared and discussed with
the community.
Post ODF support Sanitarians and community Post ODF support and monitoring is meant to be provided
health centres by sanitarians and community health centres, but follow-up
varies widely. For most communities, emphasis is on getting
to ODF with weak follow-up and redress of any slippage,
while some communities have regular follow-up towards
reaching subsequent pillars.
Technical support Some product availability Availability varies by area. Sanitation marketing is integrated
Availability of products and and follow-up with CLTS in some areas (e.g. parts of NTT). In some
services districts, sanitarians and local masons are trained in
sanitation marketing. Dependent on the capability of the
sanitarian to provide information to the community on

technology choices during follow-up of triggering.
Monitoring STBM secretariat national The STBM Secretariat (hosted by MoH) has an SMS and
Robust and regular online monitoring system web based monitoring system to track STBM progress
monitoring of ODF nationally. Indicators include: progress of triggering, number
achievements of latrines and OD population, verification and declaration
dates. Latrine access is categorized by: permanent toilets,
semi permanent, sharing and OD. There is open access to
the website, but some concerns remain about the quality
of data and the availability of databases throughout the
country.
PAMSIMAS also has a more comprehensive MIS system
which attempts to include behaviour change monitoring
indicators into the system, but the programme is still finding
appropriate indicators to do this and to identify who will

Post ODF monitoring of Post ODF monitoring weak STBM monitoring systems can show slippage of ODF
quality and sustainability villages, but this is rarely reported on. Reporting by
sanitarians is only required annually. PAMSIMAS carries out
three monthly follow-ups, including on ODF statuses.
Evaluations and Some reviews and The national Pokja undertakes a coordinated, regular, annual
knowledge sharing evaluations review for the sector, involving several main government
Evaluations, reviews and agencies related to sanitation. Studies and reviews have
learning been conducted by development partners and projects
including Plan, WSP, Pamsimas and SHAW. Results of the
reviews are usually, but not always sufficiently, shared
and agreed corrective actions from respective agencies at
national and local levels are not always followed through
diligently. UNICEF facilitates monitoring and evaluation
meetings and visits from national and sub-national levels
on STBM implementation in target provinces every year.
Where STBM is being supported, there are opportunities to
share lessons learned at WASH working group meetings at
provincial and district levels, and through newsletters and
knowledge sharing. There are currently insufficient studies
on slippage.
Information on costs and Limited cost information Some information on costs at district and provincial level but
resources for CLTS not standardized, given the diversity of the country.

1 Increased prioritization of Sanitation is higher on the agenda. The Government has established new targets for water
sanitation supply and sanitation in the National Mid Term Development Plan 2015-2019 (Rencana
Pembangunan Jangka Menengah Nasional, RPJMN) which is universal accessible, though it
is expected that unimproved sanitation will remain. However, the meaning of the targets are
unclear despite their ambition. New targets have raised awareness on sanitation in some areas
of government.
2 Focus on behaviour Specific partners, such as Public Works, are working to better support sanitation behaviour
change, not subsidies, for change through STBM and not just to allocate budgets for the construction of physical facilities
rural sanitation (usually communal). In the past, latrines/community toilets built through subsidies and full grants
were not well maintained or used in many cases.
3 PAMSIMAS programme PAMSIMAS 2 is working with sanitarians within the government system through a more
change programmatic approach, which is a change from PAMSIMAS 1 which used external health
facilitators for implementation. Sanitarians are MoH staff that have responsibility for sanitation.
This approach improves sustainability after the programme finishes and builds the capacity of
government staff.
PAMSIMAS 2 also has better alignment with community driven development programme
PNPM village selection is demand led and under PNPM (which subsidized sanitation), and
now has to work through PAMSIMAS (unsubsidized).
4 Strengthening of STBM Wider uptake of an STBM approach, strengthening of national monitoring systems and in-
approach creased support to sanitarians (e.g. through resources and training). Sector coordination has
overall become stronger.
5 Responsibility for urban Urban sanitation systems are increasingly seen as a responsibility of Public Works and/or local
sanitation governments, rather than being left to the community/household. This includes septage removal
and treatment. Still much work remains to be done on this issue.
6 New Village Law 6/2014 A new village law will direct funds to villages (Unam Desa). Although in the process of being
implemented, this change will mean more emphasis on strengthening STBM teams in villages
and improving budgeting practices.
Lessons learned
1 Engaging at the provincial Long term change is achieved by building increased ownership, accountability and associated
level takes time capacity at the provincial level in order to take responsibility for all districts within a province,
but this takes more time than going directly to the district level. There is a tendency for actors to
bypass provinces and go to the district level directly for implementation.
2 Advocacy of provincial Most NGOs and development partners now have a strong focus on advocacy. Once a provincial
governors can scale up governor and district mayor understand the benefits of sanitation and the need for prioritization,
they can have a larger impact on activities in their areas. When they put into place a regulation
for ODF communities and follow the STBM programme, this becomes a critical tool for
communicating with local governments to improve their budgets and implement the
programmes. Dissemination of the regulation to all districts and villages results in similar
regulations on STBM. District government and villages then provide budgets for STBM.

Lessons learned (continued)
3 District leader capacity There is a strong correlation between ODF districts and the strength of the Bupati (district head).
and commitment is Bupati issue regulations related to sanitation and hygiene practice, and provide incentives for
important but varies villages or sub-districts that achieve ODF status. If the Bupati advocates for ODF and it becomes
one of the programmes for the office of Bupati, budgets will be made available, regulations will
be developed and it will become the priority of the sub-district and village government due to
the strong push from the head of the district on the importance of becoming ODF. Replication
of STBM in other villages and sub-districts can be done without external support. In several
districts in NTT, for example, the average time to reach ODF from triggering was one year, but in
some villages in Sumba Timur, ODF status was gained within four months due to district
regulations and communication through churches.
4 Slippage There is evidence of slippage in some places, but the monitoring system is not attuned to pick
this up. Reasons for slippage: living near waterways which provide alternate toilets; toilet is
not what the household wants and it deteriorates over time; absence of regular monitoring or
encouragement afterwards ODF; no threat of loss of ODF status for head of village.
5 Promotion CLTS is only one tool for influencing open defecation. Other communication involving religious
leaders has increased the effectiveness of CLTS at changing open defecation practice.

1 Scale of challenge The scale of sanitation is a huge challenge because of the size of Indonesias population and
the diversity within the country. 34 million rural people still openly defecate, with 63 million not
accessing improved sanitation. Achieving universal access to sanitation for all by 2019 is a huge
challenge.
2 National government The capacity of the secretariat of the community-based Total Sanitation & Hygiene Strategy
needs to accelerate (STBM) needs to be strengthened to coordinate and assist the implementation of STBM in
STBM Indonesia at scale.
3 Variable quality and Sanitarians are government health officers with other roles and are not always available,
capacity of sanitarians motivated or monitored for CLTS triggering and follow up. In most areas, a sanitarian may be
responsible for 20 villages. Quality and capacity of sanitarians vary across locations and within
programmes. MoH, with support from partners, has developed standardized training content
and modules, but more investment is needed in longer term capacity development and in the
monitoring of performance, including incentives for sanitarians based on achievements. The
number of skilled sanitarians graduating from training is insufficient in meeting demand for
implementation and there is an overall shortfall in numbers of sanitarians needed.
4 Use of subsidies/alternate Where communities have received funds and projects from many development agencies for
funding years, including from the Government, this has created a dependency (e.g. Papua and Papua
Barat in 2004 after special autonomy applied). Subsidies and aid have undermined the social spir-
it of these communities, with working together (gotong royong) being very rare and an expecta-
tion of outside support. This is a challenge for the CLTS philosophy. After triggering, communities
seek some support or expect village funds to be used to support them.
5 No post-ODF monitoring There is no clear procedure for monitoring sustainability and slippage of previously verified
ODF communities. Post ODF monitoring is uneven and not formalized. STBM reporting is only
required annually, which is not sufficiently regular to address issues which caused the slippage.
The emphasis is on reaching ODF, with follow-up being generally ignored. Also there is no
natural progression to the other pillars of STBM.
6 Sanitation marketing Pockets of sanitation marketing only. In Papua, and many other provinces, the focus has been
more on building the capacity of sanitation entrepreneurs to produce simple and affordable
latrines, with less effort on supporting the marketing of the products.
7 Poverty and income Households need to bear the brunt of sanitation costs. In some parts of the country poverty is
high and a major barrier for households accessing sanitation.

1 ODF in targets ODF is already a target in RPJMN 2014-2019. This means the Government is responsible in sup-
porting the creation of an enabling environment and is required to monitor progress and
allocate sufficient funds to adequately manage and accelerate the STBM programme.
The RPJMN provides an opportunity to refocus efforts on sanitation and ODF communities.
2 Potential for different There is potential for the private sector to become more involved in STBM and sanitation.
partnerships For example, the Indonesian mining company Adaro carried out STBM in Tabalong regency to im-
prove sanitation and health outcomes as part of its corporate social responsibility. There is also
potential for other private companies to contribute expertise (e.g. messaging on WASH).
Partnerships with religious leaders are very important. These are critical in Islamic areas where
voluntary donations are made for less fortunate communities, but the community needs to be
organized in spending the money effectively; work is underway on such guidance.
In several areas, the police and army have also taken a keen interest in sanitation, which may be
further harnessed in a positive and participatory way.
Further decentralization of funding to the village level means the local village head will also be an
important player within STBM partnerships in the future.
3 Stronger integration into There are almost 9 million stunted children estimated in Indonesia. UNICEFs statistical analysis
health and nutrition found a 40 per cent greater chance of being stunted if a child grows up in a house without
improved sanitation. UNICEF has developed an approach paper with ideas on how to better link
WASH and nutrition interventions. There is strong potential to further develop the integration of
CLTS and nutrition, building on the pilot work begun in NTT in 2015. More outreach on STBM via
midwives as has been the case of positive examples from Aceh and better WASH facilities in
health centres are also critical here.
4 Capacity building of Potential for the professionalization of sanitarians through training, civil service job performance
sanitarians assessments and better selection of trainee sanitarians.
Plan Indonesia, 2012, Improving CLTS from a Community Perspective Approach in Indonesia.
World Bank Water and Sanitation Program, 2014, Water Supply and Sanitation in Indonesia Service
Delivery Assessment.
UNICEF 2015 Review of STBM in Aceh Timur.

KIRIBATI
KIRIBATI: Country CLTS overview
Rural sanitation
2012 2015
100
scale
90
OD population rural (2010 and 2015, mill) 0.029 m 0.029 m 49
57
Villages triggered (number) 0 135 70

50
CLTS targets in government plans No Yes
CLTS financed by government No Yes 17
40
CLTS integrated with other approaches No Yes 15
CLTS sustainable monitoring No No 3
30
Effectiveness ODF success rate 0% 76% 3
20
Scale of rural sanitation challenge 25
31
10
2012
Open defecation 49% 4,573 28,807 29,128 2000 2015
Shared sanitation facilities 3% 280 1,764 1,099 Unimproved sanitation

Total without improved sanitation 69% 6,439 40,565 42,867 facilities
Shared sanitation

The JMP estimate for Kiribati suggests a decline in open defecation from 57 per cent in 2000 to
49 per cent in 2015, with a significant increase in improved sanitation from 25 per cent to 31 per cent
during the period. In terms of population, there appears to be little impact since 2010 on the absolute
numbers of people in rural areas openly defecating in Kiribati. However, due to gaps and lags in sanitation
access data and the small population size, some caution is needed when interpreting these figures.


A concept introduced by UNICEF through the EU-KIRIWATSAN-1 programme in June 2012. In early 2013,
Kamal Kar was invited by UNICEF and the Government of Kiribati for an advocacy and capacity building
mission to Kiribati. The Ministry of Public Works and Utilities together with the Ministry of Health, Island
Councils, UNICEF, and other national WASH sector partners, piloted CLTS in North Tarawa. North Tarawa,
with a population of 5,000 people in 13 communities and an OD rate of 64 per cent, was declared
Kiribatis first ODF island in May 2013. The success in North Tarawa led MPWU and UNICEF to plan a roll-
out throughout the Gilbert Islands, using funding from the European Union (EU-KIRIWATSAN-2) and the
Government of Kiribati. One year later, over 70 communities on six outer islands declared themselves to
be free of open defecation, and the spread is continuing with CLTS in 16 (48 per cent) outer islands (out
of 33 nationwide). The EU-funded KIRIWATSAN project aims to increase access to safe and
sustainable water and sanitation, and aims to reduce WASH-related diseases in at least 70 of 139 villages
across 16 islands of the Gilbert group by 2016.

CLTS has been tried in urban areas during training with Kamal Kar when six urban villages were triggered
as practical demonstrations (the Bairiki Community, Temwaiku, Taborio, a part of Eita, a small
community in Nawerewere, and Bonriki at the Tiantaake community). Communities were active at first
but later abandoned the toilets.
MAJOR EXCEPTIONS
Ministry
Sanitation programmes
of Public Works
ADB South Tarawa UNICEF
and Utilities
Sanitation Improvement
Sector Project. Kiribati
Ministry
Red Cross pilot in
Secretariat of Health
South Tarawa. and Medical
of the Pacific MIA
Community Ministry Services
of Internal
Affairs

The South Tarawa Sanitation Improvement Sector Project is doing WASH community awareness and
will pilot trial toilets.
Kiribati Red Cross is starting a pilot project in some communities in South Tarawa, but is not using
CLTS.
CLTS scale
As of December 2014, 103 villages on 11 islands had been declared open defecation free by their Island
Councils, out of a total of 16 outer islands in the Gilbert Group. Due to limited follow-up, however, reports
of return to open defecation are frequent.
ODF success rate

ODF achievement rates have been rapid despite the prominence and community acceptance of open def-
ecation. In some communities, open defecation rates were as high as 70 per cent. The biggest challenge
to sustaining ODF rates is the limited choice of technology in fragile coral atolls. Households initially
chose to construct simple pit latrines, since they are cheap and can be built quickly, but these
can do more harm to public health if they contaminate a freshwater lens that people depend on for
drinking water. At the other side of the so-called sanitation ladder, flush toilets are inappropriate for out-
er islands since they require scarce water for flushing, as well as costly septic tanks that are prone
to leaking.
CLTS capacity
Around 280 facilitators have been trained to date. Around 45 are still active (32 facilitators, 12 natural
leaders from Abaiang, Maiana and North Tarawa, and water technicians).
At the national level, there is a group of 73 trained CLTS trainers called the Core Technical Group (CTG).
On each outer island, 20 facilitators are trained prior to triggering to support the team in each community.
As the highest ranking medical officer on the island, the medical assistants are the primary counterpart
for the CTG members, in addition to the Island Councils. In the communities, the Village Welfare Groups
are responsible for ongoing support and follow up with the community, though this has been of varying
capacity and quality.

CLTS scorecard
Policy 2010 National Sanitation General policy that promotes enhanced community
CLTS in government policy Policy. awareness of sanitation, public health and hygiene
requirements but does not contain any specific references
to programme methodologies or detailed technical
requirements.
Strategy 1 National Sanitation 1 No specific ODF targets. Plan recognizes that simple and
CLTS targets in government Implementation Plan less costly solutions will be the most appropriate and
strategies or development (10-year). sustainable; and that service improvement requires
plans 2 Government plans. ongoing community motivation and commitment.
3 EU-KIRIWATSAN -2 2 The President of Kiribati and the Cabinet have committed
Program. to achieving an Open Defecation Free Kiribati by 2015,
using CLTS as the main approach for increasing sanitation
coverage in line with the National Sanitation Policy.
3 The EU-funded KIRIWATSAN Phase I Project aims to have
safe sanitation in at least 70 of 139 villages across 16
outer islands by 2016.
Leadership Led by MPWU with CLTS is led by the Ministry of Public Works, and the Ministry
CLTS led by government presidential endorsement. of Health and Medical Services, with high level commitment
from the President of Kiribati. Island councils (Ministry of
Internal Affairs) play a key role and lead the process locally.
Finance GOK contributions. The Government of Kiribati is providing complementary
CLTS financed by funding to support the EU-KIRIWATSAN-1 programme
government because the EU project only works in about half of the
communities in the Gilbert Group (16 islands). MPWU has
put in funding to include the other half of the communities
in the CLTS programme.
Coordination Core Technical Group. A core technical team of 73 people from government and
Mechanisms for stakeholder NGOs coordinate and lead CLTS. Regular coordination
coordination meetings.

Integration WASH safety plans. To reduce the risk to communities from wet toilets that can
CLTS integrated with other lead to contamination of freshwater lenses, CLTS is being
approaches combined with participatory WASH safety planning to
identify the locations of water sources and locations of
contaminants, e.g., toilets or pig pens. Communities are
triggered to protect water sources by the better siting of
toilets.
Triggering Standardized and locally The Training of Facilitators guidance and methodology for
Standardized facilitator adapted training guide. community triggering is done by using the CLTS
training training guide prepared by Kamal Kar, but modified to Kiribati
contexts and experiences. The facilitators guide has been
translated into Kiribati for use by the team.
Facilitator quality control Developmental support for Support during facilitator development, but no follow up for
facilitators. quality control or accreditation. For two or three times, the
facilitator is provided support by the WASH team until he or
she is confident. Facilitators are allowed to lead the team,
provided the administrative requirements are in place, e.g.,
release, approval to travel, the island clerk on an island is
informed prior to arrival. Trip reports are also a requirement.
ODF ODF criteria. Criteria for ODF has been developed and is being used by
Clear ODF criteria the KIRIWATSAN Phase I project, though inconsistently.
ODF criteria three criteria for a toilet:
1 all households have a toilet with a lid to cover from flies
and available covering material to stop smells (toilets used
by all members of the household);
2 water with soap is close by for handwashing; and
3 the surroundings or village is clean (proper waste
disposal sites).

Verification protocol Verification process Criteria for ODF has been developed and is being used by
developed. the KIRIWATSAN Phase I project, though inconsistently.
Verification is by the Technical Working Group. The first
phase is to become ODF and the second is to attain
Model Clean Island status. No islands have attained
Model Clean Island status. Monitoring/assessments or spot
check template development is used on the island, whereby
the Village Working Group (committee), including the
medical assistant or nurse and any member of the
committee on the job, is trained on its use. At this stage
there is no ODF certificate provided.
Post ODF support Post ODF follow-up and monitoring assessments are
inconsistently and infrequently carried out. As with
triggering, these are done with the support of trained
personnel from the Core Technical Group, which
encompasses different ministries, natural leaders and local
engineers, medical assistants, water technicians, and trained
ODF committee members on outer islands.
Activities include meeting with island authorities and
communities, including village chairs and unimwane (elders),
for CLTS progress, household visits and general
assessments and spot checks to validate and monitor CLTS
progress for Level 2 ODF Model Clean Islands. One check
on four islands found sustained ODF of between 5 per cent
and 80 per cent.
Technical support Limited technical solutions. Researchers are working on suitable low cost technical
Availability of products and sanitation options to protect freshwater lenses of coral atolls
services with support from the New Zealand-funded Kiribati WASH in
Schools Project. Current preferences of pit latrines and pour
flush toilets are harmful to groundwater. Supply chain devel-
opment of waterless sanitation alternatives is needed.
Monitoring Inconsistently done. No centralized reporting mechanism.
Robust and regular Monitoring/assessments or spot check template
monitoring of ODF development is used on the island, whereby the Village
achievements WASH Group (committee), including the medical assistant
or nurse and any member of the committee on the job, is
trained on its use. Weak reporting links between VWG and
Island Councils. Many VWGs are inactive.
Post ODF monitoring of The island councillors are not sure of their roles in
quality and sustainability sustaining, monitoring, and strengthening or supporting
their VWG. Some island councils agree to put aside support
money during VWG monitoring activities.
Evaluations and None A CLTS implementation review is proposed within the next
knowledge sharing year
Evaluations, reviews and
learning
Information on costs and None No available cost norms, but mid-term review EU reports
resources for CLTS include budget utilization reports.

1 Scaling up of CLTS CLTS has scaled up rapidly from zero ODF communities to more than 100 within three years,
but the quality of the programme has not been maintained because of the focus on triggering
without a follow-up plan.
2 High level commitment The President of Kiribati has endorsed CLTS and called for an ODF Kiribati by the end of 2015.
Government ministries, e.g., Public Works, Health, Agriculture, are actively participating in CLTS
promotion and sanitation improvements in various ways.

Lessons learned
1 Ongoing follow up A constant commitment to monitoring, verifying and checking ODF communities is needed in
needed to sustain ODF order to sustain behaviour change for the long term. Post triggering follow-up and monitoring
assessment is needed on each island, rather than from teams based in South Tarawa, given
the logistical constraints of operating in the country. As the KIRIWATSAN project ends in June
2016, island councils need to independently continue to monitor the sustainability of
behaviour change.
2 Holistic WASH planning is Based on trials during KIRIWATSAN I and II, CLTS triggering together with participatory WASH
effective safety planning will allow communities to analyse their WASH situation and understand the link
between location and types of sanitation and groundwater sources. Villages make their own
decisions about sanitation within the context of groundwater protection.
3 Community imposed Some communities have enacted fines (ranging from US$ 5-US$ 50) for defecating in the open
fines for open defecation in order to reinforce the new social norm, e.g., in Bonriki where the water lens is very
are effective vulnerable, fines of US$ 5 have been imposed US$ 2.50 goes to a general sanitation fund and
US$ 2.50 goes to the person who caught the open defecator. There are also fines of US$ 50.00
at Antekana and Ukiangang on Butaritari Island and US$ 20.00 on Abaiang, where US$ 25.00 or
US$ 10.00, respectively, goes to the reporter, and the other half to the community. Local bylaws
are revised to include fines. Not all fines are effectively implemented however.
4 CLTS is difficult in urban Following triggering by Kamal Kar in urban areas, communities were active when first triggered
areas and started building their pit toilets and were using them, but later they abandoned the toilets
due to:
people prefering pour flush/water seal latrines, but being unable get these from the Ministry
of Health as it has stopped casting the goosenecks for toilets;
ash used for the covers being impractical;
groundwater tables being quite high in most of these villages; and
overcrowding and space being a serious issue in the Bairiki community.

1 Inadequate sanitation Pollution associated with sanitation systems threatens scarce and vulnerable groundwater
options are contaminating resources in the atoll islands. No technical solution has been found which satisfactorily
groundwater addresses environmental impact, low cost and community preferences. Household awareness
of groundwater pollution from their own sanitation leads to reversion back to open defecation.
The CLTS programme should not have been started until acceptable improved sanitation options
(i.e., appropriately designed composting/waterless toilets) were developed and available at an
affordable cost in-country.
2 Strong cultural values The Kiribati hold strong cultural views on acceptable sanitation and hygiene practices.
Handwashing is rarely practiced and households with a toilet may still have members that
continue to defecate on the beach. The mindset will take a long time to change.
3 Logistics and costs of Kiribatis 33 islands and coral atolls are spread over a vast area in the Pacific Ocean, making
follow up with outer visits to the outer islands for follow-up, verification and monitoring extremely costly and time
islands consuming.
4 Natural disasters Tropical Cyclone Pam destroyed all toilets on the coastal side of almost all islands in Kiribati.
Cyclones are an annual risk in Kiribati.
5 Monitoring Maintaining effective monitoring is challenging. Effort is needed to work with Core Technical
Group members and island authorities, medical assistant (MoH) officers, and water technicians
to ensure ways of sustaining CLTS monitoring.

1 Sanitation solution op- A coalition of government, development partners, NGOs and researchers are experimenting with
tions available alternative sanitation options which can provide better groundwater protection than
existing sanitation. This is needed before scaling up CLTS. It may be possible to combine CLTS
with sanitation marketing in South Tarawa.

LAO PDR
LAO PDR: Country CLTS overview
Rural sanitation
2012 2015
100
scale
90
37
ODF villages (number) 36 144 73

5
Enabling CLTS in government policy May be Yes 2
50
CLTS targets in government plans Yes No
CLTS financed by government Indirect No
40
CLTS integrated with other approaches May be Yes
CLTS sustainable monitoring Planned No
30
Effectiveness ODF success rate 17% 25% 9 56
20 1

10 17
2012
Open defecation 37% 270,231 1,594,361 1,698,600 2000 2015

Total without improved sanitation 44% 321,355 1,895,997 2,071,400 facilities
Shared sanitation

The JMP estimate suggests a rapid increase in improved sanitation coverage in rural areas from a low of
17 per cent in 2000 to 56 per cent in 2015. The main contributor to this increase has been the reduction
of open defecation. The latest JMP estimates that open defecation sits at 37 per cent, which suggests
that 270,000 rural households (1.6 million people) do not use a sanitation facility.

Introduced by WSP and CONCERN Worldwide in 2008, CLTS has since spread to 31 districts out of
143 nationally, in 10 out of the 17 provinces in Lao PDR (59 per cent nationally), although in some
provinces CLTS is only being implemented in one district in a limited number of villages. The biggest
concentration of effort is by WSP and SNV, and the Nam Saat in Champasak and Sekong provinces,
covering 174 villages across 10 districts. During 2015-2016, the Provincial Nam Saat in Champasak and
Sekong are planning to carry out CLTS triggering in 250 villages across 10 districts, pending government
budget availability.
CLTS is not promoted in urban areas.

International Bilateral Multi-lateral

National NGOs NGOs Private sector programmes agencies Government
Theun
Hinboun DFAT
PADECT Power
CDEA SNV Comp WB/WSP Ministry of Health
Nam Saat
Health Dutch
LBA Poverty Govern-
Action ment
Plan
Confluence UNICEF
MAJOR EXCEPTIONS
Subsidy programme
World
Vision Government poverty
programme
Implementation of CLTS remains a relatively a concentrated effort in Lao PDR, however since 2012, the
Ministry of Health, Nam Saat, has played a much greater role, especially through direct implementation
of CLTS by district health offices (including setting targets, formulation of operational plans, and carrying
out CLTS processes such as pre-triggering, triggering, follow-up/supervision, ODF verification). Provincial
health offices have the role of management, coordination, providing periodic supervision, training and
performance monitoring. UNICEF is a new entrant, having dropped its latrine subsidy programme in 2011.
Private sector involvement is a new feature with the Theun Hinboun Power Company,
implementing CLTS in selected villages in two districts of Borlikhamxay province. THPC piloted CLTS in
Nonxong village, which is home to around 650 people who moved to the village from other areas in 2009,
during the expansion of the Theun-Hinboun hydropower project. Nonxong has subsequently
become ODF. WSP commissioned two local associations, namely the Community Development and Envi-
ronment Association (CDEA) and the Lao Biodiversity Association (LBA) to implement CLTS in 40 villages
during 2011-2013. More recently, WSP commissioned SNV together with the Participatory
Development Training Center (PADECT). Plan implements CLTS in selected districts across three
provinces: Bokeo, Oudomxay and Saravanne.
WSP is providing technical assistance at the national level (Dept. of Hygiene and Health Promotion and
the National Centre for Environmental Health and Water Supply), including capacity building (TOT on CLTS
national facilitators), developing CLTS national guidelines, ODF verification, and monitoring frameworks
and operational programme guidelines on scaling up rural sanitation in the country. UNICEF, together with
development partners, is working with MoH and other ministries to come up with an
overarching WASH Policy and implementation strategy, which includes rural sanitation.

The governments programme on supporting rural sanitation targets 64 focal sites around the country.
These focal sites are identified and prioritized by the government due to their remoteness and poverty
level. The approach undertaken to address rural sanitation is through hardware subsidies for poor
households.

1 WSP: CLTS + sanitation marketing (+ handwashing with soap)
CLTS has been integrated with handwashing with soap (this is in the pilot stage) and is piloting
integration of CLTS into the Poverty Reduction Fund (PRF) programme in collaboration with the
National Centre for Environmental Health and Water Supply (Central Nam Saat). The PRF pilot project
covers 40 villages of six districts across four provinces (Attapeua, Saravan, Sekong and Savannakhet).
Sanitation marketing has been carried out by WSP alongside CLTS work in Champasak and Sekong
provinces. This has involved strengthening the skills and services of sanitation producers, and
integrating informed choice and technical knowledge with CLTS triggering. In addition, WSP, together
with East Meet West (EMW), has piloted a sanitation output-based approach. This approach
encompasses sanitation marketing with demand generation through CLTS, but adds a suite of
innovative features designed to help poor households to overcome financial barriers to accessing im-
proved sanitation and to incentivize communities and community volunteers to become ODF.

2 SNV: Sustainable Sanitation and Hygiene For All programme (SSH4A)
The Sustainable Sanitation and Hygiene for All (SSH4A) programme is implemented in collaboration
with the Provincial Rural Development and Poverty Reduction Office in Savannakhet province,
together with its subordinate offices in the three target districts (Atsaphon, Phin and Xonabouri).
Other programme stakeholders and partners include personnel from the local branches of the
ministries of Health, Education, Planning and Investment, Lao Womens Union, and the Lao Youth
Union. SNV provides capacity building, organizational and technical support from its team, which
includes associate advisors, consultants and local capacity builders. Provincial and district
governments conduct CLTS triggering, post-triggering, ODF verification and declaration based on
government standards and guideline. Provincial and district governments develop work-plan and
monitoring systems with technical support from SNV.
3 UNICEF
CTLS was integrated with WASH in schools and linked as a prerequisite for water supply provision.
4 Plan International: CLTS + SLTS
Plan focused on CLTS in communities and SLTS in schools through four topics, using toilets,
handwashing, safe drinking water and clean environments within all target schools and villages for
Bokeo and Oudomxay provinces.
CLTS scale
Due to a reliable database dating back to 2009, data shows that more than 565 villages have been
triggered using the CLTS approach since 2009, with a quarter of these in the period between mid-2014
and 2015. Approximately 144 villages have been declared ODF, although not all of the declared ODF villag-
es in 2015 have been certified yet as many were only recently declared ODF.
ODF success rate

Lao PDR has a moderate ODF success rate: 25 per cent of triggered villages have been declared ODF.
However the rate is misleading in that a number of villages were triggered in the period between
mid-2014 and early 2015, and are still pending being declared ODF. The length of time to reach ODF
from triggering is 9-10 months, but this depends on factors such as:
the activeness of village authorities and established village CLTS committees;
close post-triggering follow-up by facilitators and mobilization work by village CLTS committees; and
availability of sanitation options/materials/suppliers.
Successful triggers include: disgust, privacy, and stigma of continuing open defecation.
CLTS capacity
A total of 306 CLTS facilitators have been trained in Lao PDR through capacity development activities
supported by CONCERN Worldwide, WSP, Plan, SNV and World Vision. The main CLTS trainers have been
from the Participatory Development Training Centre (PADETC), SNV and the National Centre for
Environmental Health and Water Supply (Nam Saat). Of these, the sector has jointly trained 17 trainers
from five provinces who are now certified as national master trainers. Many of the others trained are
district-level facilitators (averaging 10 per district). Lao has records of the gender break down on two
thirds of the facilitators trained. Where records are available, most of the facilitators are males, with just
29 per cent being female. WSP, SNV and Plan report that of the combined 171 facilitators trained
between them, all are still active. For other partners, the number of facilitators still active is unknown.

CLTS scorecard
Policy National Plan of Action. In the National Plan of Action for Rural WASH, the
CLTS in government policy MoH operational government is promoting the shift from subsidy to a
programme guideline. demand based approach. However, there is still
inconsistency in terms of intervention approaches on rural
sanitation in the country. For example, even within the same
district or province some programmes promote CLTS and
others use a subsidy approach. The operational programme
guideline on scaling up rural sanitation adopted by MoH
served as a blue print for designing and implementing CLTS
in the country.
Strategy No targets for ODF. The government does not currently have a target for
CLTS targets in government achieving ODF but has set a target for achieving 80 per cent
strategies or development sanitation coverage by 2020.
plans
Leadership Nam Saat and provincial The government is actively involved in CLTS development at
CLTS led by government health offices. national levels and in implementing within provinces where
support is given by partner agencies.
Finance Limited budget support. A significant portion of the government budget used for
CLTS financed by rural sanitation is for the procurement of latrine hardware for
government subsidies. Government budget allocation for CLTS is very
low and comprises an estimated 10 per cent of the cost of
implementation. Budget is primarily used for post triggering
follow-up and ODF verification.
Coordination WASH Technical Working A WASH Technical Working Group meets regularly and
Mechanisms for stakeholder Group. discusses sanitation issues, including CLTS and subsidies.
coordination The meeting is chaired by representatives from the
government agencies (Dept. of Hygiene and Health
Promotion and the Dept. of Housing and Urban Planning).
Integration 1 WASH in schools Implementers are trialling a variety of ways to integrate
CLTS integrated with other 2 Handwashing with soap/ CLTS, including UNICEF-supported WASH in schools; WSP
approaches hygiene promotion piloting integration of handwashing with soap in Champasak
and Sekong provinces; sanitation marketing be carried
3 Sanitation marketing out alongside CLTS; and piloting integration with poverty
4 Poverty reduction fund reduction through the Poverty Reduction Fund programme
5 Nutrition in collaboration with the National Centre for Environmental
Health and Water Supply (Central Nam Saat). Discussions
are occurring on the possibility of integrating/using CLTS
approaches in nutrition, plus a new World Bank health and
nutrition project includes a component on behaviour change
which also promotes behaviour change in addressing rural
sanitation.
Triggering Technical manuals and WASH partners supported the development of a set of tech-
Standardized facilitator training guides. nical manuals and training guides which have been used to
training train facilitators. A Training of Trainers workshop has resulted
in the creation of master trainers with high level competen-
cies and skills. Nam Saat central, with support from WSP
and SNV, is consolidating all CLTS related
manuals and guidelines into a CLTS package.
Facilitator quality control Facilitator coaching and SNV conducts periodic coaching and observation of all
checks. trained facilitators and quarterly review meetings. Quality
control is not yet systematically undertaken and Central
Nam Saat is yet to take the lead in developing a facilitator
monitoring system that can be applied nationally.

ODF National CLTS manual Government approved standard criteria which is consistently
Clear ODF criteria (2013). used by partners. Criteria includes:
100 per cent of households having toilets and all
household members using them regularly.
Toilets used for the disposal of childrens faeces.
Villages establishing a responsible committee that is
active in implementing CLTS.
The village establishing rules about toilets and their use.
Villages being a model village of the 3 Cleans Program.
80 per cent of families being acknowledged as culture
model families.
Villages with good environments that are not dirty.
House yards being clean with no animals kept under the
houses.
No places for open defecation.
Toilets located 10-15 metres from water sources.
Some criteria such as using toilets for the disposal of
childrens faeces is not strictly scored if this aspect of CLTS
is not actively promoted.
Verification protocol Verification process. An agreed verification system is being used. Villages make
a request to the district health office and verification is done
by a health team plus representatives from surrounding
villages. All households are inspected and feedback is given
on adherence to the criteria and improvements needed.
A district CLTS team conducts a second assessment and
approves verification. The district governor certifies the
village as ODF. In theory, ODF status can be removed if the
village reverts to open defecation.
Post ODF support Informal support only. There is no formal or systematic post-ODF follow-up or
support. It is expected that district governments visit the
ODF villages while they are on other tasks (mother and child
check-ups, vaccinations, etc.). Plan continues to follow up
every six months to one a year after ODF is declared and
conducts checks using a monitoring ODF form.
Technical support Sanitation marketing. In WSP provinces, technical support is provided to
Availability of products and National consumer research communities by trained facilitators introducing technical
services and supply chain analysis. information to village CLTS committees after triggering,
including: sanitation informed choices, technical support to
build toilets and information regarding all available supplies
and suppliers in the area.
WSP has supported supply side strengthening through
private business capacity building in 10 districts of
Champasak and Sekong provinces, resulting in eight districts
having sanitation producers selling latrine products through
sales agents. Sanitation marketing activities have included:
the recruitment of interested enterprises and sales agents,
training for enterprises and sales agents (sales events,
business start-up, marketing/ promotion, tools development,
etc.), and sales and promotion activities in both triggered
(one week after triggering) and non-triggered villages.
Sanitation products are still limited outside of areas
supported by WSP.
There is no formal study of households moving up the

sanitation ladder from dry pit to pour flush latrines, but
reported cases are due to availability of materials and
suppliers. The national consumer research and supply chain
analysis found most rural households overwhelmingly prefer
a pour-flush latrine. Learning exchange and exposure visits
have been organized to enable concerned government staff
and the private sector to understand the sanitation
marketing approach.

Monitoring Project based monitoring No national systematic monitoring system but up-to-date
Robust and regular but consolidated reports consolidated project records are available on CLTS activities
monitoring of ODF available. since 2009. Project implementers work with government
achievements partners at village and district level to monitor ODF.
Post ODF monitoring of No systematic ODF Post ODF checks are done but not systematically and are
quality and sustainability checking. project based only. The National CLTS Manual (2103) states
that, post-ODF, the following activities shall be undertaken:
participatory action planning within communities,
supervision/follow-up on agreed actions, conduct verification
and certification, and declaration.
There is no comprehensive study of open defecation
reversion rates, but WSP gives likely reasons as:
1 Broken latrines;
2 Full latrines;
3 Difficulty in getting latrines fixed, getting materials for
fixing/new installations, getting emptying service;
4 No reinforcement of village regulations; and
5 Poor maintenance and cleaning.
Evaluations and 1 Review of CLTS pilot 2011. 1 External review in 2011 for the first CLTS pilot project
knowledge sharing 2 Scaling Up Rural (six villages) to create lessons learned and understand
Evaluations, reviews and Sanitation Workshop challenges in scaling up sanitation.
learning 2014. 2 Learning workshop on Scaling Up Rural Sanitation in
3 Exposure visits on CLTS Lao PDR 2014. Government and development partners
and sanitation marketing. implementing CLTS agreed to three key components for
the improvement of rural sanitation and hygiene:
4 Government learning
Strengthening enabling environments toward a
exchange in CLTS
sustainable, cost effective national programme for
provinces.
scaling up rural sanitation.
5. Coordination meetings. Strengthening supply chains: increase market supply
and facilitate consumer intake of affordable, aspirational
and accessible sanitation facilities for all consumer
groups, including poor and remote areas.
Demanding creation: create community demand to
stop open defecation and create effective consumer
demand, including poor consumers, for improved
sanitation facilities.
3 Exposure visits for the government technical staff at
provincial and district levels to learn about CLTS and
sanitation marketing.
4 Learning exchange for government agencies: rural
development office under the Poverty Reduction Fund and
provincial health office in WSP provinces.
5 Information exchange through quarterly and annual
meetings at district and provincial level, plus a Technical
Working Group meeting.
There is currently discussion among WASH partners to
organize another forum to exchange lessons learned.
Information on costs and Costs estimates for World Bank analysis estimates cost/village of US$ 600 to
resources for CLTS implementation and scaling achieve ODF status within 10 months (based on Nam Saats
up. capacity to cover 10 villages per year). The cost covers all
stages of the CLTS process (roadshow events,

pre-triggering, triggering, follow-up and ODF verification),
including per diem, travel/fuel, meeting costs, administrative
costs. Costs are for the district level only, excluding any
costs at provincial level, e.g., supervision, etc.
Costs for scaling up (calculation based on a scale of 25
villages/district, with an increase of 2.5 times the number of
staff needed) is US$ 28,000 per district (or US$ 1,120 per
village), covering the whole process of CLTS implementation
from the kick-off meeting to ODF village declaration.

1 CLTS guidelines The development of a standardized set of guidelines and manuals on CLTS for Lao PDR, includ-
ing a package for the training of trainers, has helped make the approach to CLTS more consis-
tent. An Operational Guideline for Scaling Up Rural Sanitation has also been developed and
approved by the Department of Hygiene-Health Promotion (MoH) that helps to guide and unify
the sector.
2 Wider acceptance of Momentum is gaining in the sector and more partners are becoming aware of the progress
CLTS made using the CLTS approach. More NGOs are applying the approach in their projects. The
government is open to and promotes the CLTS approach, recognizing that it is one among other
approaches to generate demand for sustainable sanitation.
Lessons learned
1 Cost efficiencies in There are economies of scale when scaling up CLTS. Based on simple cost-efficiency
scaling up calculations:
If implementing CLTS in 60 villages, it costs US$ 58,965 (US$ 982/village)
If implementing in 240 villages, it costs US$ 104,102 (US$ 434/village)
The cost for CLTS is reasonable if compared with the result in changes of behaviour of villagers
from open defecation to ODF.
2 Government support To scale up, support is needed from governments to be involved throughout the whole process.
needed to scale up Government commitment to sanitation and water supply is an important complement to CLTS
as government decisions have legitimacy at community level. The challenge for the future is to
make best use of both CLTS and government commitment. Advocacy for the government at
senior levels (central and provincial authorities) to allocate funding to support demand creation
for rural sanitation is crucial for working at scale.
3 CLTS stimulates latrine The introduction of CLTS, and the avoidance of hardware subsidies, has stimulated some innova-
innovation tion in latrine design and construction, and most families have been able to build toilets without
employing a mason. However, there remains a strong preference for pour-flush latrines which
are unaffordable to most poor households. Technical assistance in the design and
marketing of more affordable, hygienic latrines would potentially be very useful and help to make
scaling up possible.
4 Good facilitation skills Good quality training, followed by ongoing mentoring support, is essential for CLTS facilitators
essential and should be incorporated into plans and budgets for scaling up.
5 Triggering alone is not Triggering alone is not enough to secure community-wide, long term change in defecation hab-
sufficient its. Substantial follow-up is needed to strengthen community motivation for change and (in some
cases) to provide technical advice or logistical support with latrine construction.
6 Hygiene behaviours need CLTS is good at delivering ODF communities but does not necessarily impact other hygienic
special attention behaviours. There may be scope for including a hygiene promotion component in post-triggering
follow-up, focusing as a minimum on the key issues of handwashing with soap or ash at critical
times. Experience from other countries indicate that this can be facilitated as a community-led
process.
7 Community leaders are Community leaders play a pivotal role in the achievement of ODF status. This role should be
important nurtured and encouraged, not only to accelerate progress in the leaders own villages, but also
for scaling up promotion to surrounding communities.
8 Capacity building takes Enhancing local government capacities to fully implement the programme requires continued,
time long-term commitment.

1 Multiple criteria difficult to In order for communities to be declared ODF there are several criteria which have to be met
meet which are not directly related to ceasing open defecation behaviour. This takes a long time for vil-
lages in Lao PDR to meet all these criteria (longer compared to other countries to achieve ODF).
2 Government lacks money The government lacks funds to support implementation. Financing systems are needed.
3 Lack of capacity at district There is limited capacity for government agencies (both in quantity and quality) to carry out CLTS
level work, especially at the district level. The limited number of district staff available in Nam Saat
presents a challenge for scaling up. Partnerships with competent INGOs could potentially be
very useful if they could deploy additional field workers to support Nam Saat.
4 More affordable design For the poorest, cost is still the biggest challenge in adopting improved sanitation. Limited
needed availability and range of products in terms of affordability and desirability is a constraint.

CLTS weaknesses and bottlenecks (continued)
5 High transport costs Transport costs (both for staff to communities and supplies/suppliers to communities) increases
the cost of implementation and puts pressure on scaling up.
6 Monitoring system Monitoring and evaluation systems and tools are not yet in place, making it difficult to assess
missing progress and gaps.

1 WASH Policy and UNICEF, together with development partners, is working with MoH and other ministries to
Sanitation Implementation devise an overarching WASH policy and implementation strategy. Rural sanitation will be a
Strategy strong component of the policy. In the UNICEF-Lao Government 2015-2016 work plan, support
will be provided to MoH for the development of a National Sanitation Strategy (Sanitation Road
Map). This strategy will pave a way to move forward with short, medium and long term action
plans to eliminate open defecation.
2 Integrate CLTS with The World Bank is in the process of consultation with the Government to develop a new
nutrition and poverty programme of support for the Ministry of Health on Health and Nutrition, as well as to the
reduction National Rural Development Office on Poverty Reduction Program, which will have a
multi-sectoral approach. Sanitation will be one of the main priority areas of intervention.

MONGOLIA
MONGOLIA: Country CLTS overview
Rural sanitation
2012 2015
100
scale
90
CLTS in urban areas No Yes 27
35
0
Villages triggered (number) 10 N/A 70
21 30
50
CLTS financed by government No No
40
CLTS integrated with other approaches No No 18
30
Effectiveness ODF success rate 10% N/A
20 43

10
2012
Open defecation 27% 50,151 220,663 272,200 2000 2015
Unimproved sanitation facilities 0% 0 0 240,800 Open defecation

Shared sanitation

The JMP estimate suggests an increase in improved sanitation coverage in rural areas from a baseline of
26 per cent in 2000 to 43 per cent in 2015. A further 30 per cent of the rural population use either shared
or unimproved sanitation facilities. The open defecation rate was estimated to be 27 per cent, which
equates to 50,151 rural households (220,000 people) who do not use any form of sanitation facility.

First introduced by World Vision in September 2011. By 2013, the Mongolian Red Cross Society (MRCS)
conducted training of trainer courses on CLTS, targeting Nalaikh district in Khuvgsul province with sup-
port from UNICEF. In 2015, UNICEF plans to continue CLTS activities with the MRCS. World Vision has
implemented CLTS in a number of districts across five provinces since 2011, including Zuunkharaa, Khu-
vsgul, Bayan Ulgii, Bayankhongor and Uvurkahngai. In total, CLTS is implemented in nearly a quarter of
the 21 provinces in Mongolia.
World Vision is implementing CLTS in one of nine urban districts in Mongolia.

MAJOR EXCEPTIONS
NGO and government
programmes with UNICEF
subsidies World Vision
Mongolian
Red Cross

CLTS is a new approach in Mongolia with only World Vision and Mongolia Red Cross/UNICEF taking it up.

UNICEF Mongolias 2012-2016 County Programme focuses on WASH in Schools, however it is
supporting Mongolian Red Cross to implement community based CLTS in Nalaikh dictrict in Khuvgsul
province.
CLTS scale
More than 5,000 households have been triggered but there are no communities that have achieved
ODF status.
CLTS capacity
A total of 35 CLTS facilitators have been trained in Mongolia 15 by World Vision and up to 20 by
Mongolia Red Cross. Ten of the World Vision facilitators are active in promoting CLTS within World Vision
programmes, however the number of active facilitators within Red Cross is unknown.
CLTS scorecard
Policy 1998 Law of Mongolia on Sanitation defined as activities to eliminate adverse natural
CLTS in government policy Sanitation. and social factors having potential impact on public health,
and to prevent the public health from diseases. Normal
sanitary conditions are defined as a healthy and safe
environment for a human to work and to live in.
Strategy No WASH strategy or plan. No CLTS targets in government strategies or national
CLTS targets in government development plans.
strategies or development
plans
Leadership No CLTS not lead by government at central level, however there
CLTS led by government is interest in CLTS from local level government in areas
where it is implemented.
Finance No There is no government financial support to CLTS and no

CLTS financed by formal CLTS programme yet.
government
Coordination No Very little sector coordination generally, with a number of

Mechanisms for stakeholder NGOs implementing without cooperation. No CLTS working
coordination group.

Integration No No combined approaches.
CLTS integrated with other
approaches
Triggering No standard training. There is no standard training for facilitators, however the
Standardized facilitator CLTS manual has been translated into Mongolian.
training
Facilitator quality control No There is no proper mechanism to check and maintain the
performance and quality of facilitators. World Vision has an
annual review of CLTS progress which includes facilitator
review.

ODF No criteria. No national criteria for ODF developed yet.
Clear ODF criteria
Verification protocol No No verification protocol developed yet.
Post ODF support No No post ODF support system yet.
Technical support No No sanitation marketing.
Availability of products and
services

Monitoring No progress data. No national monitoring system.
Robust and regular
monitoring of ODF
achievements
Post ODF monitoring of No No sustainability monitoring.
Evaluations and No No reviews and evaluations.
knowledge sharing
Evaluations, reviews and
learning
Information on costs and No No information available on costs.
resources for CLTS

1 Some increase in spread The number of communities implementing CLTS has increased, with World Vision implementing
of CLTS in 5 out of 21 provinces, including one urban area.
2 Increase in trained As a result of training by World Vision and Mongolian Red Cross, the number of trained
facilitators facilitators and the capacity to implement CLTS has increased.
Lessons learned
1 Facilitator skills are The effectiveness of CLTS and the speed of households to become ODF depends on
important for success facilitators skills and regular follow-up.

1 CLTS not mainstreamed CLTS is yet to be implemented on a scale which can produce evidence that advocates the use of
in government plans and the approach. There is limited interest in the approach from national level government.
programmes
2 Continued use of The provision of latrine subsidies remains the default approach to sanitation improvement.
subsidies
3 Climate Technical challenges created by sub-zero temperatures in winter which freezes water seal toilets
and excreta.
4 Population density and Mongolia has the lowest population density in the world. Improving sanitation behaviours of
mobility large nomadic and semi-nomadic populations is a challenge.
5 Poverty Acute poverty in rural and peri-urban communities is a barrier to obtaining sanitation.

1 Begin to formalize CLTS Establish common systems and approaches for CLTS based on past experience, e.g., facilitator
training, ODF criteria.
2 Build on interest at local Where CLTS is implemented, local governments are showing interest in the approach. There is
government level potential to build momentum from this interest.

MYANMAR

MYANMAR: Country CLTS overview
Rural sanitation
2012 2015
100
6
scale
CLTS spread: % of country 12% 29% 16
90 6
Capacity developed (trained facilitators) 158 579 60 10
Enabling CLTS in government policy May be No

50
40
CLTS integrated with other approaches No No 77
30 54
20
10
2012
Open defecation 6% 455,684 2,141,715 2,546,000 2000 2015
Shared sanitation facilities 11% 835,421 3,926,478 4,455,500 Unimproved sanitation

Shared sanitation

The JMP estimate suggests a rapid increase in improved sanitation coverage in rural areas from a
relatively high baseline of 54 per cent in 2000 to 77 per cent in 2010. A further 17 per cent of the rural
population use either shared or unimproved sanitation facilities. The open defecation rate was estimated
to be 6 per cent, which equates to 456,000 rural households (2.1 million people) who do not use any
form of sanitation facility.


Introduced by UNICEF and Save the Children in 2010. By 2012 CLTS had spread to eight districts in four
regions and states (12 per cent geographical coverage). In 2015, CLTS had spread to 25 townships, and
more than 530 villages in five states and regions (29 per cent). UNICEF is the largest implementer of
CLTS in more than 480 villages but this is a small fraction of the total 64,000 villages. Local government
has a role in the monitoring and verification of direct implementation. Township medical officers in
particular are involved in the whole process of CLTS including monitoring and follow up, as well as ODF
declaration in areas where implementation is carried out by NGOs.
CLTS is not currently implemented in urban areas in Myanmar.

MHAA Save the

HEALTH
Children
UNICEF
SVS
IRC
MAJOR EXCEPTIONS
Subsidy programme
Government and
Development partners

Government still subsidizes toilet construction in some areas. Most of the WASH actors including
development partners still provide subsidies for sanitation both in development and humanitarian
programmes.

Some modification to CLTS with partial subsidies for materials, especially latrine superstructure, after
triggering stage.
Some NGOs link CLTS implementation as a prerequisite for obtaining community water supply.
CLTS scale
More than 530 villages have been triggered but only 33 villages are certified as ODF while a further 60
villages have achieved ODF status but not yet certified. In addition, 200 villages will be ready to declare
ODF in 2015. The average period to do pre-triggering, triggering and post-triggering is six to nine months
(depending on geographic location).
CLTS capacity
A total of 579 CLTS facilitators have been trained in Myanmar, although only 71 of these facilitators are
currently active. Of those trained, 520 are from the Department of Health, Department of Rural
Development and Department of Education.
CLTS scorecard
Policy No national sanitation policy No national sanitation or CLTS policy. No policy on the use
CLTS in government policy of subsidies.
Strategy No WASH strategy or plan No rural sanitation strategy. Department of Rural
CLTS targets in government Development, DoH and Department of Basic Education are
strategies or development now planning to develop Rural Water Supply and Sanitation
plans Strategy in 2015.
Leadership 1 Department of Health, 1 CLTS not lead by government at central level. The DoH
CLTS led by government Environmental Sanitation ESD is not yet convinced about CLTS.
Division (ESD) 2 In some townships supported by UNICEF and NGOs,
2 Township level township medical officers are actively supporting CLTS
implementation.
Finance No government financial The government allocates very little money to the sanitation
CLTS financed by support to CLTS sector with zero allocation for CLTS. DoH is planning to
government provide a smart subsidy for households with children under
5 and the Department of Rural Development is providing
subsidies to households with people with disabilities,
households with elder people and households in conflict and
disaster affected areas.
Coordination No CLTS working group There are WASH technical working groups but no CLTS
Mechanisms for stakeholder working groups. No annual review of CLTS implementation.
coordination

Integration Child survival CLTS is integrated with Young Child Survival and
CLTS integrated with other Health and hygiene Development programme under DoH, WASH in schools proj-
approaches ects, and community water supply projects. Hygiene promo-
Nutrition tion such as 4 cleans (clean hands, clean water, clean toilet
and clean food) is an integral part of all CLTS projects. Some
NGOs integrate CLTS with hand washing/hygiene, health
and nutrition integrated projects. Due to the limited scale of
CLTS, integration is also on a small scale.
Triggering Facilitator training modules CLTS standard training modules have been developed both
Standardized facilitator in English and the Myanmar language based on standard
training CLTS training of Kamal Kar. UNICEF, together with the
DoH, is developing a CLTS toolkit that will include training
modules, guideline, verification checklist, etc. There is no
institution for capacity building of CLTS trainers.
Facilitator quality control None There is no proper mechanism to check and maintain the
performance and quality of facilitators.
ODF National ODF criteria drafted A national ODF criteria has been drafted and used by most
Clear ODF criteria implementers in Myanmar but it has not yet been approved
and adopted by government. The interim ODF criteria
includes:
1 No evidence of open defecation in the whole village.
2 Every latrine has a proper lid for the latrine pan and cover
on the ventilation pipe of the pit to prevent flies entering
in the pit.
3 Childs faeces are disposed in the latrine pit or properly
covered.
4 Everyone must wash their hands with soap or other soap
substitutes such as ash or sand after visiting the toilet, as
indicated by the presence of soap and water at the latrine.
Verification protocol Interim verification protocol Interim protocol developed which will be formalized after
a CLTS review. Members of the verification team include:
Representatives from the DoH (Central Health Education
Bureau & Environmental Sanitation Division) in collaboration
with state/regional health education bureau, township
medical officers, basic health staff such as a health
assistant, lady health visitor and midwife; other local
governmental officials such as township administrators,
township education officers who are already trained as CLTS
facilitators. Sub teams check the entire village for
compliance with all elements of ODF criteria. ODF
certification is for a one-year probation period.
Post ODF support ODF villages are visited by basic health staff from the DoH
such as lady health visitors, midwives or Public Health
Supervisors in a monthly basis to monitor and maintain the
ODF status. The community is encouraged to build more
new latrines to replace shared latrines. Regular follow up
by basic health staff is still weak as the staff are overloaded
with many tasks. Implementers do not have the funds to
conduct continuous monitoring after the village achieves
ODF.
Technical support No sanitation marketing Very limited product range with the main latrine model a
Availability of products and simple fly proof latrine. No sanitation marketing support.
services During rainy season, and in areas of high ground water table
eg. Ayerwaddy Delta, direct bamboo lined pits are
unsuitable. Alternative pour flush latrines with offset
concrete pit are unaffordable.

Monitoring No national monitoring Manual monitoring at programme and project level only by
Robust and regular system NGO staff and basic health staff. No development or
monitoring of ODF implementation of a national M&E system.
achievements
Post ODF monitoring of No official guideline or policy DoH staff such as lady health visitors, midwives or Public
quality and sustainability Health Supervisors are assigned to ODF declared villages to
monitor the ODF status on a monthly basis, but there is no
guideline or policy to reinforce the monitoring process. No
sustainability checks of ODF; slippage is also not monitored.
Evaluations and CLTS review planned in 2015 MoH and UNICEF are conducting a CLTS review during
knowledge sharing 2015. The findings and recommendations will be shared with
Evaluations, reviews and WASH implementers and government.
learning Dialogue on the CLTS approach is occurring at a national
level on a limited basis.
Information on costs and No national cost norms but The estimated unit cost per village to implement CLTS
resources for CLTS data available from UNICEF is around US$ 1,200-1,300 (6 month period)/village;
US$ 1,500-16,00 (8 month period)/village (UNICEF).

1 Trialling of CLTS Development of draft processes and procedures for CLTS implementation including a training
procedures manual, draft ODF criteria, and certification process. There are some discussion on CLTS at the
national level.
2 Some increase in spread The number of communities implementing CLTS has increased.
of CLTS
Lessons learned
1 Lack of policy prevents Without a supportive policy environment, it is difficult to scale up CLTS. Unless the government
scaling up adopts the approach, supports it with resources and policy implementation, it will remain
piecemeal and at the project level.
2 Local health and CLTS is more successful where there is the full engagement of the township medical officer
community resources and basic health staff, and where the local authority is involved in the whole process. A strong
are key WASH/CLTS committee can motivate the community to achieve or declare the ODF status in a
very short time.
3 CLTS training Strong training is important. CLTS trainers should preferably be part of a government-led team
at the state/regional level to conduct CLTS training and support for ODF verification. Refresher
training is needed for CLTS ToT training, for CLTS working groups and networks that are led by
the DoH with the support of UNICEF.
4 Large villages are It difficult to implement CLTS in large villages (more than 200 households) and achieve
challenging 100 per cent ODF status in a short period, without sufficient and skilled staff.
5 Rewards and recognition Timely rewards and recognition of ODF villages at the local and national levels supports
of ODF status are maintenance of ODF status. Village ODF acknowledgement ceremonies should be held as soon
effective as the villages are declared for ODF. Acknowledgement and reward of ODF villages from
national level government motivates the continuation of ODF status, helps motivate other
communities, and attracts national attention through the media to other parts of Myanmar.
Inviting declared villages to take part in the DoHs National Sanitation Campaign is effective.
Exchange visits among all CLTS implemented villages are useful for learning and motivation to
sustain ODF status.
6 Low quality latrines result The construction of low quality latrines, especially digging pits in high water table areas and in
in OD slippage sandy soil leads to collapse. When the latrines cannot be used for several months it results in a
reversion to OD.

1 CLTS not mainstreamed CLTS is yet to be adopted as a national approach and included in strategic plans and targets.
in government plans and Although township medical officers are actively supporting CLTS implementation in some
programmes townships, policy makers and high ranking Government officials need to buy in to CLTS
implementation. Many organizations are still counting the number of latrines rather than ODF
achievements. Implementation is on a short-term project basis and not part of a longer term
Government programme.
2 Continued use of The acceleration of progress and effective scaling up of sanitation is undermined by competing
subsidies or contradictory approaches in the same location, particularly the use of hardware subsidies that
are not employed in a targeted manner to the poor, nor delivered in a smart way.
3 Lack of Government Basic health staff and other relevant Government staff are overloaded with many tasks and do
resources to implement not have the time to dedicate to CLTS.
4 Limited latrine There are few latrine options available for households. Affordable technology solutions are yet to
technologies be developed for challenging environments i.e. flooding and high water table areas.

1 CLTS review to shape Recommendations from a proposed CLTS review in 2015 will guide the revision of documents
future direction such as a training guidebook, facilitator handbook, ODF verification checklist, TOR of ODF
verification teams, and the definition of ODF. This will strengthen and standardize the CLTS
implementation processes. A CLTS tool kit relevant to Myanmar will be prepared following
the review.
2 Rural WASH Strategy Myanmar is in the process of developing a national Rural WASH strategy. Inclusion of the CLTS
approach in the Rural WASH Strategy will improve implementation, especially after
modifications following the CLTS review in 2015.
3 CLTS Technical Working The establishment of a national level CLTS technical working group or network will help to
Group coordinate field level implementation, share the lessons learnt and provide technical support
needed at the field level.
4 Improved leadership The leadership and guidance from national level to state/regional level is vital to implement CLTS
at scale except in flooded areas, conflict affected areas and remote areas, etc.
5 Additional CLTS pilots Additional CLTS townships/villages in the next few years will contribute as pilots for learning and
advocacy. There is more of a consensus in the sector that a pro-poor mechanism is needed,
a guideline will be drafted in 2015 which could then be piloted.
6 Scaling up through Integration with other programmes such as livelihoods cash for work activities can increase the
integration scale of CLTS.

PAPUA NEW GUINEA
PAPUA NEW GUINEA: Country CLTS overview
Rural sanitation
2012 2015
100
scale
CLTS spread: % of country 95% 86% 16 13
90
Enabling CLTS in government policy No Yes

50 68 71
40
CLTS integrated with other approaches No Yes
30
20
10
2015 Rural sanitation coverage 13 13
2012
Open defecation 13% 154,126 863,107 1,079,800 2000 2015
Shared sanitation facilities 3% 35,568 199,178 Unimproved sanitation

Shared sanitation

The 2015 JMP estimates indicate that there has been no change in access to improved sanitation in rural
areas of Papua New Guinea since 2000 with the rate remaining at 13 per cent. Open defecation is
estimated at 13 per cent while the biggest gap is in the use of unimproved sanitation, which has
increased to 71 per cent. There are still 154,000 households (860,000 people) who do not have access to
any form of sanitation in rural areas.


CLTS was introduced by Oxfam in 2008, with implementation expanded by ChildFund and Live and
Learn in 2009. By 2012 CLTS was being implemented in 19 provinces, largely through the efforts of an
EU-Rural Water Supply and Sanitation Program. Currently CLTS is supported in around 12 of the
22 provinces in Papua New Guinea, but only in selected districts within those provinces. The widest reach
is by local NGO Touching the Untouchables (TTU) who is working in two districts of Eastern
Highlands province, and in one district covering 30 wards, but altogether covering 12.5 per cent of the
entire province.

MAJOR EXCEPTIONS
World Water Subsidy programme Department
TTU Oxfam Aid of Health
Vision Oxfam NZ
Faith based NGOs
ChildFund
CLTS implementation is led by NGOs including WaterAid, ChildFund, World Vision and TTU in the Eastern
Highlands province. Government involvement is at the local level through partnerships with NGOs,
and the training of Provincial Environmental Health Officers at the national level for roll out within
provinces. The extent of the roll out by provincial Environmental Health Officers is unknown, but it is
believed to be limited.
CLTS has only been trialled on a small scale in urban settlements by World Vision, whose staff have been
trained to try out the feasibility in WVs urban projects.

Oxfam NZ in Bougainville is using CLTS to generate demand alongside the provision of subsidized latrine
slabs and vent pipes for VIP latrines.

CLTS implementers in Papua New Guinea require that latrines meet two minimum technical criteria: pro-
vision of a sealed pit and a vent pipe.
1 CLTS + Healthy Islands concept
The Healthy Islands concept encourages health promotion in sub-settings such as homes, schools,
villages and markets; and covers safe motherhood, child health, immunization, protection against
communicable diseases, and quality of life. CLTS fits well with many of the activities and principles of
this Pacific-specific approach. Implementation of the concept has lacked finance and support,
however a framework of action for revitalizing implementation of the concept was agreed in 2011.
Strategy 7.3.1 of the National Health Plan 2011-2020 is to increase the roll out of the Healthy Islands
strategy, however the extent to which this approach is utilized in Papua New Guinea is uncertain.
2. WASH, Community Health and Maternal Health
CLTS is integrated into other programmes of NGOs:
WaterAid integrates CLTS into WASH programmes.
TTU has built CLTS into all of its village health worker (VHV), village birth attendant (VBA) and
community health worker (CHW) training workshops. ODF villages are selected and presented to
Oxfam (PNG) to provide rainwater harvest systems to these villages. So far five villages have
benefited from this strategy.
World Vision implements CLTS in all (100 per cent) of its WASH projects. Sanitation is linked to the
provision of water supply, with water supply hardware being subsidized. World Vision also includes
sanitation and hygiene components in its Maternal, New Born and Child Health (MNCH) projects in
Bougainville, Port Moresby Urban Settlements and Madang.
ChildFund PNG integrates CLTS with hand washing/hygiene, provision of water supply and other
projects such as nutrition and livelihoods.
Local modifications of CLTS include: promoting improved sanitation in locations where households al-
ready have toilets, adapting to the local context, using local materials as teaching aids during training. TTU
also introduces a minimum standard ventilated improve pit latrine structure design during the
community engagement so the participants can see what a health promoting toilet looks like.

CLTS scale
As of 2012 more than 470 villages were reported to have been triggered using the CLTS approach, with a
further 189 triggered since then. There is no central register of ODF communities.
ODF success rate

As of June 2015 an estimated 144 villages have been certified as ODF (123 added since 2012). The suc-
cess rate of ODF communities from those triggered is 18 per cent. The most experienced NGO (TTU)
reports 23 out of 97 villages triggered have been certified as ODF a success rate of 24 per cent. Other
NGOs have not achieved full community ODF but the amount of OD has reduced at the household level.
The time between triggering and achieving ODF ranges substantially from three months to as much as
12 months where a community has difficult conditions such as flooding. It has also been observed that
the usage of latrines at night is an issue due to fear of being bitten by snakes and sorcery. More typically
the average time to reach ODF as reported by World Vision and TTU is five to six months.
Successful triggers include: disgust, privacy, convenience, pride and stigma of continuing OD, good
health, but also status in terms of wealth and respect.
CLTS capacity
A total of 510 CLTS facilitators and community representatives have been trained in Papua New Guinea.
Community representatives are village health promoters, and village birth attendants who are trained for
awareness rather than to conduct triggering. It is uncertain how main trained remain active but probably
half to one third are still active.
CLTS scorecard
Policy WASH Policy 2015 PNGs First National WASH Policy was passed in early 2015.
CLTS in government policy The policy aims for 100 per cent total sanitation; with a
focus on changing behaviour through the promotion of safe
sanitation facilities, leading to ZOD. Subsidies for sanitation
should be limited but can be considered if carefully targeted
to promote access for the poorest, disabled, for improved
menstrual hygiene, for innovation, for sanitation in
Strategy GOPNG Development No ODF targets. Only targets for 70 per cent of population
CLTS targets in government Strategic Plan 2010-2030 with access to improved sanitation by 2030.
strategies or development
plans
Leadership No government leadership Government is not leading CLTS. DoH supports CLTS but
CLTS led by government does not lead implementation.
Finance No government finance No government funding for CLTS.
CLTS financed by
government
Coordination No formal coordination No coordination mechanism on CLTS. NGOs conduct

Mechanisms for stakeholder mechanism implementation independently. Some improved WASH
coordination coordination with recent WASH policy but not specifically for
CLTS.
Integration WASH and Maternal Health Integrated with WASH, handwashing, maternal health, and
CLTS integrated with other village health as part of NGO programmes.
approaches
Triggering No standard training No organized capacity building training for CLTS. There are
Standardized facilitator no standard training modules.
training
Facilitator quality control NGO-only quality control Facilitator performance is checked by individual NGOs who
also provide refresher training in some cases. There is no
consistent approach to monitor quality although TTU as a
trainer has developed a monitoring and reporting template,
which includes a tool to assess the learning competency of
CLTS facilitators in the community. Upon assessment and
verification by the trainers (TTU), the facilitators will be
certified as CLTS practitioners. There is no centralized
training institution although the Environmental Health
Department of the Faculty of Health Sciences at Divine
Word University could be considered.

ODF No formal ODF criteria There is no nationally defined ODF criteria. Implementers
Clear ODF criteria use their own criteria, which vary from no obvious faeces
(including childrens), covered latrines and tippy taps through
to every household having a VIP latrine, management of
human and animal faeces, and handwashing facilities with
soap. Inconsistency of ODF criteria between NGOs.
Verification protocol No agreed ODF verification No consistent verification protocol, partly due to variable
process ODF criteria. Verification differs between implementers but
usually involves Provincial or District Health staff or district
WASH committee in the verification process. No
mechanism for losing ODF status however the general view
is that communities will take pride in their achievement and
try to maintain the status.
Post ODF support Not systematic follow up Where NGOs have achieved ODF villages, post ODF support
is through local implementers, or this is left to local health
promotion authorities to follow up. Only TTU has a pro-
cess which includes monthly visits by staff to facilitate the
continuity of ODF, assess the community understanding of
ODF, see if the community has initiated other projects either
in relation to health, education, agriculture or others and
provide information and advice where needed.
Technical support Limited information on Some technical information on latrine options introduced
Availability of products and products after triggering by NGOs, for example models of VIP
services latrines, and training on latrine building. No standardized
approach or research on low cost suitable options or
markets. Some areas better served by sanitation suppliers
than others, but usually limited to major townships.
Household innovation is high but yet to be capitalized on.
Some NGOs subsidizing latrine products and transport, but
also adapting sanitation to some difficult environments.

Monitoring No national monitoring No centralized register or database for ODF villages. ODF
Robust and regular system criteria is monitored at the project level by individual imple-
monitoring of ODF menters through their own staff or local partners, but not
achievements always effectively. Monitoring is done manually then entered
onto computer. No data on slippage.
Post ODF monitoring of Project level checks Some post ODF monitoring through WASH Sustainability
quality and sustainability Assessments (WaterAid) and sustainability checks (TTU) of
ODF villages.
Evaluations and Very limited sector No known evaluations of CLTS, except as part of individual
knowledge sharing information NGO programme WASH evaluations.
Evaluations, reviews and Some sharing of lessons learned though events such as
learning WSP sustainability workshops or reporting at government
meetings but not with a view to improve CLTS practise on
a regular sector-wide basis. Site visits to sustained ODF
villages contributed information to the WASH policy.
Information on costs and No standard costs No information available.

resources for CLTS

1 National WASH Policy The recently approved PNG National WASH Policy 2015 is the first WASH policy in the country.
2015 The policy gives official recognition to CLTS as a suitable sanitation approach to achieve the
objective of reaching ODF communities. The policy gives clarity about the use of subsidies and
only employing them if targeting the very poor, in challenging environments and for other special
conditions. The policy development brought stakeholders together and awareness on sanitation
to the forefront, and it is hoped that this collaboration and awareness will continue.

Lessons learned
1 CLTS can reduce conflict CLTS can be applied in socially challenging environments. TTU has six tribal fighting villages that
have been trained in CLTS and now have toilets, animals fenced, rubbish holes, footpaths lined
with flowers and drainage. As a result of CLTS the communities have agreed to stop fighting and
have reached a ceasefire agreement and are now working towards a peace agreement. These
communities were influenced by the sanitary and hygiene transformation that happened in their
homes and village.
2 Self reliance and In a country where Government services are poor, CLTS has shown people that they can be
innovative development self-reliant and improve sanitation for themselves without waiting for the Government.
Communities have shown innovation in building VIP toilets, but have also improved their homes
and village environments. Collective goals in the CLTS process have also sets a foundation for
other developments to build on e.g. literacy, agriculture, tourism, law and order and peace, and
gender equity and equality.
3 Integration supports CLTS cannot be a stand-alone activity or programme. It needs projects like safe motherhood,
sustainability rural water supply system projects and livelihood projects to support sustainability of
ODF villages.

1 Sanitation is not a Sanitation has not been a priority for the Government in the past and it has not received any
government priority attention. There are misconceptions within the Government about subsidies and the roles of
Government departments.
2 Facilitator capacity still Influencing the community mindset leading to behaviour change is not an easy task and needs
weak facilitators who are skillful. It is difficult to cultivate and sustain good facilitators.
3 Subsidies not standard in Subsidies are still given by NGOs for sanitation e.g. ChildFund PNGs WASH project gives every
practise household in its participating communities hardware materials to self-construct latrines with
some community contribution. Hardware material for a standard designed VIP latrine costs
about K800.00 (US$ 290).
4 Difficult to scale up CLTS is entirely NGO implemented, and therefore lacks budget and scale. Without financial
without Government support from the Government, INGOs and the private sector for CLTS in Papua New Guinea it
will be difficult to scale up. A consistent and sustained driver (Government at all levels) is
needed to drive the progress in scaling up CLTS.
5 Weak sanitation supply Despite community innovation there are few latrine choices, especially low cost toilets for
chain households. The sanitation supply chain in undeveloped.
6 Land issues Most of Papua New Guinea is customary land. It is sometimes difficult to apply CLTS where
there are land issues and disputes. Settlers on other peoples land only construct makeshift
sanitation facilities for temporary use and these are not sustainable.

1 WASH policy sets future Approval of the WASH Policy and CLTS being one of the standard approaches to be
direction implemented for sanitation with proper planning that can be taken to scale. The policy will
help to create opportunities to make CLTS a standard approach in implementation in
Papua New Guinea.
2 Improve sector practise The WASH Policy provides the framework to begin strategy development and other enabling
environment factors such as standardization of facilitator training, ODF guidelines, verification
processes, monitoring, and learning to improve sector practise.
3 Institutionalize facilitator Potential opportunities to improve facilitator training include establishing a CLTS training module
training through the Environmental Health Department of the Faculty of Health Sciences at Divine Word
University; and through the establishment of a CLTS foundation in Goroka, Eastern Highlands
province to provide capacity building support for TTU and other organizations that are
implementing CLTS. TTU sees the opportunity for CLTS training to be conducted in educational
institutions in the district, particularly in lower and upper primary schools and vocational schools,
in the church and through youth groups.
4 Potential for ODF district Through the NGO TTU, Henganofi district in the Eastern Highlands province may be the first
ODF district in PNG by 2016. This could be a potential model and inspiration for other districts to
become ODF and integrate CLTS with rural water supply and livelihood projects.

THE PHILIPPINES
THE PHILIPPINES: Country CLTS overview
Rural sanitation
2012 2015
100
scale 10
CLTS spread: % of country 10% 18% 18
90
1
18


50
CLTS targets in government plans Yes Yes
CLTS financed by government Indirect Yes
40
CLTS integrated with other approaches No Yes
71
CLTS sustainable monitoring No Yes
30 57
20
10
2012
Open defecation 10% 1,155,715 5,663,003 5,718,300 2000 2015
Unimproved sanitation facilities 1% 115,571 566,300 1,429,600 Open defecation

Shared sanitation

The JMP estimate suggests a steady increase in improved sanitation coverage in rural areas from 45
per cent in 1990 to 69 per cent in 2010, and 71 per cent by 2015. Open defecation has reduced from 18-8
per cent of rural households between 2000 and 2015, although there are still 5.7 million rural people that
do not use any form of sanitation facility. As of 2015 71 per cent of rural households use
improved sanitation.
The National Sustainable Sanitation Plan sets a goal of all barangays or villages being ODF by 2022,
in seven years time.

Introduced through the development of the Sustainable Sanitation in East Asia Philippines programme
led by the Department of Health in 2007, with support from WSP. Training of facilitators was given by
Kamal Kar in 2010, supported by UNICEF. Since then, CLTS has spread to 15 out of 82 provinces and
cities in the Philippines (18 per cent geographical coverage). In some provinces CLTS has been scaled up
throughout the province, e.g. Quezon province, as part of the Department of Social Welfare and
Development (DSWD) Pantawid Program and through the Integrated Provincial Health Office (IPHO) in
all 39 municipalities. Masbate province recently adopted a Rural Sanitation Graduation Framework, also
known as the phased approach, as its strategy this includes CLTS as an important step to go from
Grade 0 (open defecation) to Grade 1 (zero open defecation). The Masbate scale up is being

implemented through the Provincial Health Office. In Typhoon Yolanda (Haiyan) affected areas, CLTS is
also implemented widely across a number of provinces, including Leyte and Eastern Samar, as part of the
Haiyan recovery programme phased approach to total sanitation (PhATS).
Through the National Sustainable Sanitation Plan, the Department of Health (DoH) has supported the
roll-out of CLTS in all provinces through capacity building for the 15 Regional DoH Coordinators who are
tasked to scale-up CLTS in the respective provinces in their regions. The roll out strategy depends on
cascading training for implementers at provincial level who in turn train health staff at municipality and
barangay level. However, there is currently no national mechanism to monitor this roll out following the
initial training (and no obligation of subnational level to report upwards), therefore the scale of actual CLTS
implementation through the DoH programme is unknown.
Main implementing agencies prioritize areas for CLTS is based on various combinations of high open
defecation, low health and nutrition status, high poverty rates and vulnerable disaster areas.

Two major programmes both of which aim to support the DoHs Zero Open Defecation Program have
contributed to the expansion of CLTS the UNICEF-supported PhATS being implemented in Masbate,
Cotobato and in Haiyan-affected areas, and the WSP-World Bank supported Scaling Rural Sanitation
Program being implemented in six provinces.
The development of PhATS under the WASH Cluster strategy has led to an increase in the number of
international NGOs implementing CLTS, including through the adoption of the approach by traditional
humanitarian NGOs. Integration of CLTS in the Department of Social Welfare and Development (DSWD)
Pantawid Program has the potential to significantly increase coverage of CLTS messages across the five
regions participating in the pilot programme, and eventually beyond.
CLTS is not promoted in Metro Manila since it is a peri-urban region, which implements the National Sew-
erage and Septage Management Plan. However, as part of UNICEFs shift from emergency
response to development in peri-urban areas such as Tacloban City and Zamboanga City, CLTS is being
adapted and included as part of the overall recovery strategy.
CAPS
ACF
Plan WSP UNICEF DOH
ASDSW
Oxfam
OND
HSD Mahin- Save the
tana Foun- World CRS Children
dation Vision
DSWD
Relief Islamic
Inter- Relief
national Worldwide
MAJOR EXCEPTIONS
Samartians Subsidy programmes
ACTED Purse IMC
LGU: Municipal toilet
bowl distributions
Major Non-CLTS programmes

Local Government Units (LGUs), including municipalities and provinces, continue to finance the
distribution of free toilet bowls in rural communities even where CLTS has been introduced, as some
stakeholders remain unconvinced that a non-subsidized approach can provide the level of sustainable
service that is demanded by rural households and expected by local governments. In UNICEF areas
implementing the phased approach, it has been agreed that LGU distribution of toilet bowls/materials/
cash rewards will only come after the certification/verification of ODF.

UNICEF also implements WASH in Schools, Day Care, and Tahderiyyah (Muslim Day Care Centres)
which complements CLTS.
A number of CSOs continue to have a supply driven approach to sanitation programming for example,
building high-cost toilets for families as part of emergency recovery programmes. Where these are being
implemented in the same or neighbouring geographic areas as the CLTS-based programmes, this has
created challenges for getting communities to engage in building their own toilets.

1 Total Sanitation
In the Haiyan-affected areas, PhATS follows the Rural Sanitation Graduation Framework of three
levels of sanitation from G1 Zero Open Defecation to G2 Sustainable Sanitation, and G3 Total
Sanitation which includes solid waste management and waste water treatment. The Rural Sanitation
Graduation Framework was developed prior to the Haiyan emergency and was being piloted in
Masbate and Cotobato (however, this is not yet adopted at the national level as the standard
approach). In accordance with national guidelines, ZOD certification (G1) includes handwashing (with
one of the indicators for certification being 100 per cent presence of water and soap in/near toilets), as
well as safe disposal of child and elderly persons faeces. The approach strictly encourages no
external subsidy from G0 (open defecation) to G1 however the community is encouraged to help
each other to be able to build toilets (called bayanihan in Tagalog). Collective rewards and incentives
are provided after achieving ZOD (G1) status to encourage the communities to move from G1 to the
next level of the framework (G2), which includes sustainable sanitation solutions. The incentive
system aims to make it possible for everyone to have improved toilets, even the poorest of the poor.
The follow-on stages also address other relevant WASH problems, such as having toilets in
government institutions (such as schools, day care centres, rural health units, etc.), solid waste
management and waste water treatment, safe management of animal excreta, protected water sourc-
es and water points, and water quality testing.
2 Social Welfare Programmes
As part of a pilot programme, sanitation has been integrated in the Family Development Sessions
(FDS) of the Department of Social Welfare and Development (DSWD)s Conditional Cash Transfer Pro-
gram (locally dubbed as the Pantawid Pamilyang Pilipino Program or 4Ps). FDS include hygiene and
sanitation messages, and some of the triggering tools used in the CLTS Approach, BCC Campaigns
Tools and choice catalogue for low cost sanitation options for rural areas where 4Ps grantees are
found and organized as Parents Groups at the barangay level. WSP is assisting the DSWD in the
WASH integration within its three core protection programmes Conditional Cash Transfers, Kalahi
CIDSS community driven development programme, and Sustainable Livelihoods Program. WASH Inte-
gration in DSWD Programs is piloted in six regions, 14 provinces, 37 municipalities with
approximately 80,210 Pantawid grantees to gain access to a toilet by 2016. The 4P programme targets
individual households, however DSWD staff have had some success at advocating to local mayors or
chief executives to aim for ZOD for whole municipalities with DoH staff triggering
non-Pantawid community members.
3 School/ECCD Hygiene Promotion
The Department of Education implements the Essential Healthcare programme which institutionalizes
daily group handwashing and toothbrushing in schools. In UNICEF-supported areas, implementing
partners engage schools and Early Childhood Care and Development (ECCD) Centers by providing
capacities to day care workers, school health promoters, parents, and caregivers in institutionalizing
hygiene promotion for school-aged and under five year old children, in support of the EHCP
programme. These activities complement the CLTS approach being implemented at the
community level.
4 Disaster Risk Reduction
The CLTS approach encourages poor communities to build their own toilets without being so
dependent on external subsidies. They realize that they can build their own toilets using indigenous
materials which will increase resiliency among families. In this way, they can bounce back
immediately after a disaster since they have enhanced their indigenous knowledge and capacities to
address their hygiene and sanitation needs without waiting for outside help. The community WASH
plan is also integrated in the barangay Disaster Risk Reduction and Management Plans as well as
Contingency Plans, giving an extensive reach on WASH-related issues.

CLTS scale
According to development agencies as of May 2015 an estimated 473 barangays have been certified
as ODF, however there are more than 42,000 barangays in the Philippines and the national target is for
60 per cent of barangays (25,000) to be ZOD by 2016. There is no centralized monitoring database that
records the ODF status of barangays at the national level, while regional DoH offices have different ways
of monitoring ODF barangays. Although the number of ODF barangays could be higher than reported,
the country appears likely to fall short of its target by 2016.
ODF success rate

As of May 2015 the Philippines has triggered 677 barangays and 473 (70 per cent) have been certified
ODF. Haiyan area has been most successful with 364 barangays so far declared ZOD out of 431 triggered
(84 per cent success rate). UNICEFs development programme has a 29 per cent success rate (101
triggered, 30 ODF); and WSP a 54 per cent success rate (145 triggered, 79 ODF). Average triggering to
ODF is two to five months, but longer for difficult barangays. Achieving ODF in WSP pilot areas in
Sarangani was very slow with five years for some barangays to reach ODF. Achievement was
accelerated through the development of sanitation action plans at barangay level and focussing on LGU
service delivery. In Haiyan affected areas, where PhATS advocates are appointed in the barangay,
triggering to ODF self-declaration can be achieved in 2-6 weeks but these areas have benefitted from
massive investment and support from CSOs (UNICEF implementing partners) to achieve these results.
CLTS capacity
The Philippines has significant CLTS capacity with at least 978 facilitators trained through multiple training
courses since 2008. DoH has 30 trained Regional Coordinators (master trainers); UNICEFs regular
programme has trained 403 facilitators consisting of barangay officials, community health volunteers,
rural health midwives, rural health nurses, school teachers, and heads of line agencies and community
health committees; the UNICEF Haiyan programme has trained 160 facilitators from Region VI to VIII (129
facilitators from the villages and municipalities and 31 NGO partners); with 385 facilitators in WSP-sup-
ported areas (Quezon 163; Negros Occidental 157; Negros Oriental 30; and Sarangani 35). DSWD
has conducted additional training on their own through the Municipal Links however the number of facili-
tators is unknown.
All the DSWD trained facilitators remain active, as do the 160 UNICEF trained facilitators for Haiyan areas.
Only 16 of DoHs facilitators are active due to attrition form retirement or facilitators moving to a new
position. Only 60 facilitators (15 per cent) of facilitators from UNICEFs regular programme are still active.
CLTS scorecard
Policy 1 DoH Administrative Order 1 National policy under DoH Administrative Order
CLTS in government policy 2010-0021) 2010-0021 Declaring National Sustainable Sanitation as a
2 Local policies and National Policy. CLTS stated as an approach to reach ZOD
executive orders towards sustainable sanitation.
2 In some areas barangay and municipal level executive
orders on achieving ZOD are institutionalizing planning,
resource and budget allocation.
Strategy 1 National Sustainable 1 NSSP produced by the DoH includes the following
CLTS targets in government Sanitation Plan 2010-2016 objectives to have been achieved by June 2016:
strategies or development 2 Municipal five-year All LGUs have declared sustainable sanitation as
plans strategic plans a policy
60 per cent of barangays declared Zero Open
Defecation (ZOD)
By 2022 100 per cent of barangays to be ZOD.
2 At the local level, the Municipal WASH Task Force sets
ZOD targets within their five-year strategic plan.

ENABLING ENVIRONMENT (continued)
Leadership 1 Lead by DoH at central 1 At central level DoH develops and implements policies,
CLTS led by government level including the National Sustainable Sanitation Plan. DoH
2 Local leadership provides operational strategy for scaling up rural sanitation
programme nationwide. DoH regional Coordinators are
in charge of rolling out CLTS in their respective provinces
however not all are able to do training due to lack of funds
at provincial level.
2 WASH taskforces at Provincial and Municipal level for
planning, monitoring for allocating resources for the
programme to ensure implementation and sustainability.
Barangay WASH Taskforces monitor the programme
implementation. In Haiyan-affected areas LGUs lead work
planning, and budget allocation.
Finance 1 Central level funding for 1 DoH allocates an average of Php 1 million (<US$ 22,000)
CLTS financed by CLTS every year at the national level for the CLTS programme
government 2 Municipal budget (capacity building and guidance).
allocation 2 Local governments under the UNICEF program and WSP
pilot areas are using and increasing annual investment
on WASH providing budget for implementation of the
programme, staff salary, hardware subsidy, transport,
facilitator training, and rewards/incentives for
ZOD barangays.
Coordination Subnational coordination Stakeholder coordination at subnational level but lacking
Mechanisms for stakeholder government led national coordination or annual reviews:
coordination WASH taskforces at provincial, municipal and
barangay level.
Monthly stakeholder meetings in the
Haiyan-affected area.
Integration 1 DSWD Pantawid Program 1. Integrated with conditional cash transfer programme to
CLTS integrated with other 2 Rural Sanitation target very poorest households. Also integrated with
approaches Graduation Framework other DSWD programs including community driven
(known as PhATS in development and sustainable livelihoods programmes.
Haiyan areas) 2. Integrated with total sanitation which envisions the
3 WASH in Schools and creation of an ODF environment with promotion of
early Childhood and supply-side interventions, safe disposal of liquid and solid
Development Centres wastes; the promotion of health and hygiene practices;
and the strengthening of the enabling environment for
sanitation and hygiene, through a phased and holistic
approach to sanitation development.
3. Programmes that support WASH in Schools and Day Care
Centres aim to reinforce ZOD behaviours and messages,
and to enable children to become agents of change within
their communities.
Triggering 1 EOHO standard CLTS 1 DoH standard 4-day training module which has been
Standardized facilitator training courses progressively localized and enhanced from the trainings
training 2 Regional training centres conducted by Kamal Kar since 2008. A selection criteria
and knowledge hubs for the trainees is also set. Environmental and
Occupational Hazard Office (EOHO) of the DoH organizes
3 National Sanitarian course the CLTS trainings using the standard module.
2 PhATS Manual developed for CLTS/Demand Creation
including facilitator training in Haiyan-affected areas.

3 Regional hubs with the capacity to be a CLTS training
school (e.g. Bicol University). The University of the
Philippines Manila through its School of Health Sciences
is being capacitated to become a CLTS/PhATS training
school to provide quality-controlled training and serve as
one of the leading CLTS knowledge hubs in the country.
4 National Sanitarian Training Course by the University of the
Philippines-College of Public Health includes CLTS.
Facilitator quality control Facilitator follow up not fully 1 DoH trained facilitators are monitored six months after
formalized or consistent the training and requested to prepare an action plan or
re-entry plan, however follow-up is not consistent.
2 CLTS Facilitators Exchange in Masbate province with
practical triggering experience and structured reflection.

ODF Guidelines on Verification Nationally approved criteria for ZOD barangay certification:
Clear ODF criteria and Certification of Barangay Use of functional toilet
ZOD Status DoH Availability of soap and water at or near the toilet (for
Department Memorandum handwashing)
No. 2015-0221
Proper disposal of babies and elderlys faeces
No visible faeces in the surrounding area
Evidence of a barangay action plan to move up the
sanitation ladder towards Sustainable Sanitation
Additional guidelines in selected areas to enforce stricter
implementation and sustainability:
Ordinance enforcing the availability of toilets to all
households and penalizing open defecation practices.
Shared household toilets should be shared by 10 people
or less (20 people or less in emergency situations).
Verification protocol Guidelines on Verification ZOD criteria in National Guidelines includes self-declaration
and Certification of Barangay after all households checked by barangay leaders or
ZOD Status DoH sanitation volunteers, sample of 10 per cent by verification
Department Memorandum team, certification and reward (including cash); reporting to
No. 2015-0221 province, regional and central level.
Municipal level verification teams comprise Municipal/City
Health Officer, Sanitation Inspector, DOH Representative,
plus one third-party member (e.g. staff from the Province,
regional or national DoH (DoH representative based in the/
province), civil society organization, NGO, district).
Haiyan-affected areas includes G2 certification for
sustainable sanitation.
No criteria yet for certifying municipalities, provinces
or regions.
Post ODF support DoH Guidelines ZOD status and its improvement should be monitored every
3 months by Sanitary Inspectors and the data reported to
the Municipality/City. The ZOD status can be revoked if
the barangay does not sustain its status according to set
criteria. ZOD Barangay is expected to proceed to next ladder
step leading to total sanitation and possible nomination to
the DoH-National Search for Barangay with Best Sanitation
Practices (NSBBSP). Local ordinances are in place to ensure
post-ODF support and scaling up. However, frequency of
monitoring is lower compared to post triggering.
Technical support Unli Asenso campaign Sanitary products generally available.

Availability of products and Sanitation marketing in DoH can provide technical support on sanitation marketing
services Haiyan-affected areas and toilet construction.
In Haiyan-affected areas supply chain strengthening has
occurred. Sanitation marketing training is provided under
programmes.
Technical support is integrated into the DSWD Family
Development Sessions. Using the Unli Asenso Choice
Catalog, households are made aware of options that can
meet their various needs (coastal or flood prone areas,
mountainous, or plain geographical areas; waterless areas;
transients and the landlord would not allow digging in their
temporary dwelling places). Costs: not more than P5,000
(US$ 109) for complete package options using indigenous

materials. Aspirational concrete structures as high as P8,000
(US$ 174) but not more P10,000 (US$ 218).

Monitoring Programme-based No centralized national ZOD monitoring system by the DoH.
Robust and regular monitoring Individual agencies supporting the ZOD Program have their
monitoring of ODF own monitoring systems. All ZOD criteria are monitored. The
achievements WSP SURS monitoring tool tracks the progress of
sanitation programme from the conduct of CLTS
Facilitators training to the actual access of toilets and the
verification of ZOD status. UNICEF piloting mobile data
collection system in Regions 6 and 8 by gathering sanitation
and ODF data from the barangay up to the municipal/city
level. Data management is done by the provinces while
oversight monitoring is done by the region.

Post ODF monitoring of ZOD barangays are required to be visited by sanitation
quality and sustainability inspectors every three months, after ZOD certification. In
Haiyan areas sustainable sanitation (G2) monitored every 3
months by Sanitary Inspectors and the data reported to the
Municipal/City. The G1 or G2 status can be revoked if the
barangay does not sustain its status according to set criteria.
Evaluations and Evaluation of CLTS not done yet. Evaluations and reviews of
knowledge sharing programme approaches:
Evaluations, reviews and 1 Rapid Assessment (2014) of WSP-DSWD convergence
learning areas to measure the outcome of the Enhanced-Family
Development Sessions (E-FDS), i.e. incorporating CLTS
and BCC in the Pantawid process
2 Enabling Environment for Scaling Up Sustainable
Sanitation and Hygiene in the Philippines (Robinson for
UNICEF, July 2012);
3 Scaling-Up Demand and Supply for Rural Sanitation
(REECS-DOH-WSP-UNICEF, April 2013);
4 Development of a Multi-Stakeholder Implementation
Strategy for Scaling-Up Rural Sanitation (Robinson for
UNICEF, August 2013);
5 Research on Development of Hygiene Behaviour Change
of Elementary Schoolchildren in the Philippines
(International Water Center for UNICEF, 2013).
DoH holds annual consultative summits with Regional and
Provincial Sanitary Engineers. It includes the sharing of best
practices in the implementation of sanitation programmes.
The recent PRO-WATER programme brings WASH actors
together to review the respective programmes that have
been done so far.
In Haiyan-affected areas, UNICEF implementing partners and
other INGOs convene regular monthly meetings, which pro-
vide a forum for sharing experiences, lessons, challenges,
and best practices in the implementation of the programme.
WSP and UNICEF assisting local and national (DoH)
knowledge exchanges including review of ZOD verifications,
local M&E activities, tools and systems in place for
municipality of Malungon (Sarangani province) and
municipalities of Aroroy, Cawayan, Milagros and Monreal
(Masbate province).
Information on costs and Programme costs available No standard costs/norms developed but costs for
resources for CLTS but no standardized costs UNICEFs regular programme are approximately US$ 227
norms per village with US$ 25 per household for post-triggering
(this includes the costs of establishing capacities and
systems at municipal and barangay levels, and the cost of
implementing the complete Graduated Rural Sanitation
Framework not just the CLTS component). WSPs inclusive
estimates for village triggering (excluding DSWD
programme delivery costs) are US$ 1.10 per household.
Costs for Haiyan-affected areas have an average of US$
10 per beneficiary including CLTS and other support (i.e.
implementation of the complete Graduated Rural Sanitation
Framework).

1 National CLTS Guidelines Previously there was no official guide for CLTS implementation process. DoH has approved the
National Guidelines for Verification and Certification, as an Administrative Order in January 2015.
The guidelines have to be reviewed to consider feedback from LGUs based on their experiences
in verifying and certifying ZOD barangays. A consultation with regional sanitary engineers and
partners on the implementation of the guidelines is yet to be conducted.
2 Need for capacity building CLTS rollout needs to be more than just a one-time training for potential trainers but needs
to be supported by ongoing capacity building and the development of systems to support and
monitor rollout, as well as by more adequate dedicated resources for this programme.

Most significant changes since 2012 (continued)
3 CLTS is one part of the It is now recognized that CLTS is only one piece of the overall sanitation programming required
sanitation solution to ensure that the Philippines reaches its NSSP targets. In addition to behaviour change through
CLTS, there needs to be sustained communication to reinforce hygiene and sanitation
messages; strengthening of the availability of affordable sanitation products and services for
low-income households, and development of the enabling environment for supportive WASH
governance and municipal services such as solid waste management and wastewater
treatment.
4 Local government Local governments now take the ZOD programme to scale by implementing using their own
ownership funding. The introduction of CLTS paves the way for conducting a Municipal Sanitation Action
Plan in which CLTS is treated as a major component of the action plan.
5 Integration of CLTS in CLTS is integrated with conditional cash transfers, WASH in Learning Environments, and
various programmes Graduated Rural Sanitation framework (including the PhATS programme). CLTS is seen as one
part of a comprehensive WASH programme which can be implemented in a phased approach.
6 Marrying CLTS with Bringing CLTS together with sanitation marketing has helped increase coverage and rate of
sanitation marketing uptake of hygienic latrines. Lessons have also emerged on efficient sequencing of the twp
approaches, including the enhancement of the enabling environment.
7 Improved monitoring ZOD monitoring has been developed using a participatory approach (e.g. forms) and trying to
use real-time monitoring tools (e.g. the use of smartphones using the ODK software) however,
these pilots need to be further developed and integrated into a national system.
Lessons learned
1 Subsidies undermine Initial resistance to CLTS could be expected as it discourages traditional sanitation hardware
CLTS uptake subsidies. Subsidies continue to be an issue. The Governments and other major agencies
commitment to shifting towards a no subsidy approach will be a major determinant of the
future of CLTS. CLTS will be more effective if communities are not covered by subsidized
sanitation programmes or are less exposed to such programmes.
2 Diffusion is effective for LGUs and local sanitation champions are contributing to the spread and success of CLTS. Once
scaling up they have the idea and skills for CLTS, local leaders and champions see the results of the
programme and decide to take it to scale. LGUs have independently triggered barangays, and
some villages have declared ZOD without being triggered because the community has heard
of the benefits of ZOD that nearby communities have been enjoying e.g. the village is clean
and free of diseases. Local chief executives (LCEs) who believe in the ZOD Program and CLTS
approach are embracing this and sharing their own stories and narratives with other LCEs from
other provinces and towns. The media is also gradually picking up sanitation news.
3 Sanitation marketing In areas where OD is still practised, people in general have a notion that the construction of
information important for sanitary toilets is costly. CLTS under the concept of TSSM, recognizes that there are low cost
sustaining change and easy-to-construct toilets that could help address OD in communities. CLTS is useful in areas
where there OD is common. After triggering, addressing the demand for improved sanitation
and new positive behaviour has to be sustained through BCC/Communication for Development
campaigns (i.e. Unli Asenso Pag May Inidoro; Goodbye Dumi, Hello Healthy) and reinforced
by local ordinance. It has to be embedded in the municipal development plans/annual
investment plan.
4 High quality facilitators Participants to the CLTS Facilitators Training must be strictly pre-qualified in order to ensure
are critical effectiveness during rollout. There is a need for cooperation and collaboration among
government organizations on sourcing talented facilitators. Experience suggests that quality
facilitators are one of the key success factors for CLTS, however facilitators also need support
mechanisms in place in order to roll out CLTS e.g. budget, technical assistance, monitoring etc.
5 Timely monitoring The monitoring mechanisms and monitoring skills of facilitators and focal persons need to be
improved to respond better to issues that the community faces during CLTS implementation.
The importance of timely follow-up and partnership of all stakeholders (e.g. formation of WASH
Taskforces) for monitoring hastens the process.
6 Children can influence Children and teachers are important in changing the behaviour towards OD. In UNICEF areas,
parents separate triggering of children at the same time as parents has a strong impact on parents
emotions and motivations. If children are at school and not present for triggering then one-time
real food and faeces demonstration/triggering of children in school can be considered in CLTS.
The role of teachers is very important for the follow-up and strengthening the feeling of disgust
and the stigma of OD practice.

1 Recurring annual natural Major natural disasters that annually impact human lives, properties and productivity create
disasters unique challenges and setbacks for sanitation progress.
2 Continued subsidies Communities and people are used to highly subsidized programmes and wait for money despite
it being made clear in the CLTS triggering sessions that no subsidies would be provided.
3 Weak human resources Human resource capacity is lacking in some areas. Quality training and careful selection is
needed to ensure appropriate skills for key roles of: DoH regional coordinators, sanitary
inspectors, CLTS facilitators, and local actors.
4 Soil type and toilet The type of soil in areas where toilets are built requires expensive innovation e.g. septic tank,
construction reinforced pits etc. There had been requests to DoH to support technical trainings at the LGU
level on the construction of improved toilets over the pit latrines.

1 Building on success to Successes of CLTS particularly in ODF communities (sitios/barangays) can be used in replicating
replicate and scale CLTS in other rural communities. In particular there is an opportunity for LGUs that have
successfully implemented CLTS to speak up/advocate for the programme to be taken up by
their peers.
2 Institutionalization Having an institutional structure and delivery mechanism in place would greatly help selected
and trained CLTS facilitators from within the DoH organization and local level could create a
permanent support structure and delivery mechanism that can be utilized in scaling-up CLTS in
the country.
3 National Coordination If a national inter-agency committee/platform for coordination could be established, it would
mechanism help to ensure that the various national programmes that support NSSP are properly aligned and
linked, and investments are maximized in terms of impact/results.
4 DSWD integration DSWD programmes integrating WASH in achieving targets for social adequacy can be rolled out
scaling up on a large scale.

SOLOMON ISLANDS
SOLOMON ISLANDS: Country CLTS overview
Rural sanitation
2012 2015
100
scale
90
66 66

50
CLTS financed by government Indirect Yes
40
30
19 19
20
10
2015 Rural sanitation coverage 15 15
2012
Open defecation 66% 47,559 299,624 143,700 2000 2015
Shared sanitation facilities 0% 0 0 61,100 Unimproved sanitation

Shared sanitation
Source: 2015 JMP estimate; United Nations Population Division (2014) Annual Rural Population 2015. facilities
Source: 2009 Population and Housing Census. Improved sanitation

The JMP estimate suggests no change in improved sanitation coverage in rural areas between 2000 and
2015. Open defecation is still high at 66 per cent in rural areas with more than 47,000 rural households
(300,000 people) not using any form of sanitation facility.

Introduced by an Australian Volunteer for International Development (AVID) with support from the
Governments Environmental Health Division (Rural Water Supply and Sanitation Program) in May 2012
in two communities in Malaita province.
In 2013, the UNICEF brought Kamal Kar to the Solomon Islands to introduce CLTS and conduct a CLTS
national training of trainers workshop with representatives from Government and a range of NGOs.
During this workshop, eight communities close to Honiara were triggered; four of these were included
in the World Vision peri-urban WASH programme and continuous programme support has been provided.
The other four communities were in the UNICEF and Live & Learn project school areas, but no specific
CLTS follow-up was done.
Currently the two main implementers are World Vision Solomon Islands (Temotu 20 villages; Makira
10 villages; Guadalcanal five villages), and Live and Learn (five villages in Isabel). UNICEF provides
support to both NGOs and Government.

CLTS is yet to be implemented at scale beyond the pilot stage, however in February 2014, a national
Rural WASH Policy was endorsed stipulating a no-subsidy approach, and in March 2015, a five-year
national RWASH Strategy was approved which focused on nation-wide roll-out of a standardized
CLTS approach.
MAJOR EXCEPTIONS
Ministry of
Subsidy programmes UNICEF
World Red Health and
ADRA Vision Medical
Cross
Rotary Club
Caritas
Churches Live and Save the
Constituency Learn Children
Development Fund

Almost all CLTS programmes in Solomon Islands are modified: in some communities CLTS is used in
combination with PHAST; NGOs specify how communities should construct latrines and handwashing
facilities; indirect subsidies may also be included.
CLTS scale
CLTS has been implemented in four out of nine provinces but on a small scale with approximately 50 out
of 1,800 communities triggered (2.7 per cent). No communities have achieved ODF status yet.
CLTS capacity
A total of 41 CLTS facilitators have been trained in the Solomon Islands, with about five facilitators still
active.
CLTS scorecard
Policy National RWASH Policy (Feb. CLTS is identified as one participatory approach that can be
CLTS in government policy 2014) used to improve sanitation coverage. The policy is endorsed,
and is in the early stages of implementation. The policys
vision is for all Solomon Islanders to have easy access to
appropriate sanitation, as delivered through participatory
zero-subsidy approaches.
Subsidies will still be considered where the only
environmentally appropriate technical solution falls outside
the financial means of the average household (e.g. Compost
toilets, toilets suitable for people with disabilities), education
facilities and health facilities.
Strategy National RWASH Strategy The five-year national RWASH Strategy approved in March
CLTS targets in government (March 2015) 2015 focuses on a nationwide rollout of a standardized CLTS
strategies or development approach and has targets for nationwide sanitation coverage
plans by 2024. 100 per cent ODF status is required.
Leadership SIG Leading Policy, Strategy The Solomon Islands Government (SIG) with support from
CLTS led by government and Targets UNICEF has led the setting of CLTS strategies and targets.
In the next phase, SIG will lead the coordination of the
National RWASH Strategy, with support from provincial
teams and NGOs. The SIG MoH and Medical Services
(MHMS)/Environmental Health Department (EHD) will focus
only on contracting and the M&E of the RWASH in the
country, and software components of CLTS.
Finance Ministry of Health and For 2015, the SIG MHMS has allocated approximately
CLTS financed by Medical Services funding for 17 per cent of the Environmental Health Budget for CLTS.
government implementation Of this, 41 per cent is for consultancy/staff, 23 per cent for
transport, and the remainder for supplies.

Coordination WASH Stakeholder Group A Government coordinated WASH Stakeholder Group meets
Mechanisms for stakeholder quarterly. CLTS and National RWASH policy objectives are
coordination included in discussions. A National Sanitation and Hygiene
Campaign Technical Working Group was formed in 2015
to progress demand-led sanitation programmes, including
CLTS.
Integration Limited implementation and therefore no integration with
CLTS integrated with other other programmes as yet.
approaches
Triggering No standardized facilitator training as yet, but there is

Standardized facilitator ongoing development by the MHMS. Following the approval
training of the National RWASH Strategy, standardized training
modules and methods will be developed.
Facilitator quality control Facilitators are employed by partner NGOs. There is no
systematic performance and feedback mechanism for
quality of CLTS facilitation, however it is assumed that
NGOs monitor performance.
UNICEF developed a database of CLTS trainers, which will
be maintained by SIG in the future.
ODF There is no nationally adopted ODF criteria, however this
Clear ODF criteria will be specified as part of the development of the national
RWASH Strategy.
Verification protocol No verification protocol has been agreed yet. It is to be

developed under the RWASH Strategy, and will involve
standard criteria and designation of responsibilities e.g. NGO
programme managers and provincial RWASH managers.
Post ODF support Not yet defined; no community has achieved ODF status
Technical support Technical resources are still being established and it is
Availability of products and anticipated that these will be provided throughout the
services implementation of the CLTS approach. There are plans to
strengthen the sanitation supply chain in the next 2-3 years,
but CLTS implementation is only in infancy.
Monitoring None. A monitoring system will be developed after the pilot
Robust and regular project in the central province and NGO project sites in other
monitoring of ODF provinces reach full scale. Monitoring will be coordinated
achievements at the national level, but implemented at a provincial and
community-level through Government and service delivery
partners. The guidelines for monitoring are yet to be
established. Initially, monitoring will be done manually,
although the government is investigating a combination of
manual and electronic data collection for the future.
Post ODF monitoring of No ODF communities.
Evaluations and CLTS Triggering Two evaluations of CLTS triggering are available, but no
knowledge sharing documented evaluations post-triggering. Lessons can be
Evaluations, reviews and shared in the WASH Stakeholder Group.
learning
Information on costs and Not available due to the limited implementation of CLTS. The
resources for CLTS costs of scaling up to meet SIG target of ODF in 10 years
has not been calculated. MoHs Strategic Plan for rural Water
supply, sanitation and hygiene (NHMS 2015) identifies US$ 6
mil plus technical assistance to deliver the CLTS approach.

1 National RWASH Policy The country has now identified the need for large scale improvements in sanitation, as reflected
and Strategy in funding for the sector and government policy. The RWASH Policy and Strategy endorse CLTS
as a method of implementation and ODF as a target, and intend to resolve a number of the
previous barriers to addressing the lack of sanitation and poor health status.
2 CLTS trials The number of triggered communities has increased since 2012. This experience allows lessons
learned to be fed into national strategies and guidelines for scaling up.
Lessons learned
1 Continual engagement Better results are achieved when implementers continue to monitor, interact and work with
communities to achieve ODF status. CLTS does not stop at triggering and sustained community
interaction is needed throughout the process until the community reaches ODF.
2 Triggering Triggers that work best to mobilize the community include: disgust (after the demonstration of
flies landing on faeces); desire for good health of children; and medical costs.

1 Lack of coordinated While the National RWASH Policy and Strategy help guide the sector there is still no coordinated
national approach national approach for CLTS.
2 Ad hoc implementation CLTS is still implemented on a small scale without the deliberate targeting of priority areas.
Location depends on where implementing NGOs operate and where pilots are accessible for
implementation and monitoring.
3 Lack of monitoring and There is no systematic review, monitoring, and sharing of lessons from implementation.
review

1 Scaling up and improving Clear commitment to CLTS in SIG policy, proposed sector coordination through RWASH, and suf-
sanitation coverage ficient resources, provides an opportunity for CLTS to be used consistently across the
country to achieve ODF.
There are currently no ODF communities in Solomon Islands, so there are opportunities for CLTS
to improve sanitation coverage. It is believed CLTS will spread rapidly once triggered and people
know they have been ingesting faecal matter.
2 Economic and gender CLTS provides an opportunity to improve family health and economy, prevent harassment of girls
benefits and women using remote latrine locations, facilitate menstrual hygiene privacy for women and
girls, facilitate other economic benefits such as savings and reduce security risks for
vulnerable people.

TIMOR-LESTE
TIMOR-LESTE: Country CLTS overview
Rural sanitation
2012 2015
100
scale
90

55
Villages triggered (number) 761 1,000 70

50
CLTS targets in government plans Draft No 31
CLTS financed by government Indirect No 6

40
7
CLTS sustainable monitoring Yes No 6
30
20
27
10
2012
Open defecation 36% 51,603 283,818 269,400 2000 2015

Shared sanitation

The JMP estimate suggests improved sanitation coverage in rural areas at 27 per cent in 2015. While this
appears to be a decline since 2000 it is more of an adjustment between the proportion of improved and
unimproved facilities during this period. Importantly, open defecation rates have fallen by a third, from 55-
36 per cent in 2015.

Introduced by WaterAid in 2007. Since then, CLTS has spread to all 13 districts in Timor-Leste
(100 per cent geographical spread), and to approximately 80-128 sucos (villages) out of 401 rural sucos
(20-30 per cent).20
20 Sector Planning Tool July 2015 records 80 sucos, while development partners separately estimated a total of 128 sucos.

Bia
Fraterna Hula AMAR Water
Ministry of
Aid DFAT Health EHD
BESIK UNICEF
MALEDOI ADRA
NTF Plan
MAJOR EXCEPTIONS
SERVB
Subsidy programmes
HTL FUTIL
World Red Cross: CVTL
Vision TL Government:
HIM ETADEP Infrastructure (DNSSB)
LBF
Timor
Aid
Since 2012 there has been a consolidation of local NGOs implementing CLTS with both local and
international NGOs leaving the sector. UNICEF is implementing in six districts, the DFAT BESIK
programme is in one district (Bobonaro), Plan International and WaterAid are implementing in two
districts each, while World Vision is working in three districts, and ADRA has limited presence in two
sub-districts in the Viqueque district. BESIK supports the secretariat for coordination of the Bobonaro dis-
trict ODF plan, which is the only district to have a district-wide plan for achieving ODF. In Bobonaro out of
five administrative posts (50 sucos) BESIK is taking care of three administrative posts (25 sucos), UNICEF
one administrative post (18 sucos) and World Vision one administrative post (seven sucos). BESIK and
UNICEF also provide support to the MoH to coordinate CLTS nationwide. The MoH stopped implement-
ing in early 2015.
CLTS is being implemented in semi-urban settings such as district and sub-district headquarters but not
in major urban areas such as the capital city Dili.

Cruz Vermelha de Timor-Leste (CVTL) is the national branch of the Red Cross, which receives substantial
WASH finance through the international Red Cross network, and is an influential stakeholder in both the
emergency relief and development sectors in Timor-Leste. CVTL has favoured a subsidy-based approach
to sanitation improvement, and remains one of the key stakeholders not implementing CLTS. A recent
review of its subsidy approach showed sanitation coverage initially of 85 per cent, with slippage to about
86 per cent of that, resulting in a final coverage estimated at 73 per cent. CVTL is working in several
districts across the country and the subsidized approach is negatively impacting on districts and
communities where CLTS is also being promoted.
World Vision Timor-Leste is new to CLTS and transitioning from a subsidized approach to a completely
non-subsidized approach and is training staff to adapt to CLTS. In one of the three districts where it
operates, Aileu, World Vision provides subsidies for concrete slabs to the village WASH committee who
distributes them to most families, however this on a very small scale covering only a few villages.
The Ministry of Public Works National Directorate for Basic Sanitation (DNSB) has in the past had
funding for latrine subsidies to vulnerable households, however without a system in place for the
distribution of these subsidies or agreed criteria for vulnerable households no subsidy latrines were
built. DNSB had planned to support 86,000 vulnerable households, however this would have seriously
undermined CLTS and caused high expectations for support in every community. Currently DNSB has no
funding for vulnerable households but together with partners is developing systems to target subsidies
through post-ODF incentives to move up the sanitation ladder, and SMART subsidies.

PAKSI
BESIK has supported the MoH in delivering a PAKSI programme that includes hand washing with
soap, with a major HWWS campaign in 2012-2013. PAKSI (Participatory Community Action to
Sanitation and Hygiene In Tetun language) is a localized version of CLTS. PAKSI evolved in 2012 from
the lessons of the early CLTS experiences in Timor-Leste; the phased sanitation approach in the Na-
tional Basic Sanitation Policy; the success of the DNSA community action planning (CAP) approach to
water supply development; and the decision that the MoH district offices should lead the process. The
PAKSI approach is a participatory process for community-based ignition, planning and action to stop
open defecation and wash hands with soap. PAKSI includes a form of CLTS modified to suit Timorese
conditions and cultural sensitivities, notably by focusing on disgust rather than shame as the main
trigger for behaviour change, and is a structured approach designed to be easier for field
workers and communities to understand and support.
Schools WASH
CLTS is integrated with WASH in schools.
Nutrition
UNICEF/World Food Programme/MoH are leading an EU-funded nutrition project in three districts.
UNICEF is implementing CLTS in all three districts (together with BESIK and World Vision in
Bobonaro; alone in Ermera and together with Plan in Ainaro) and leading the integration of nutrition
and CLTS. Partners are currently working out how to develop comprehensive behaviour change
messages that include WASH and nutrition and are properly sequenced. DFAT may also trial an
integrated nutrition and WASH approach in Manufahi. In Timor-Leste, where there is severe child
malnutrition, sanitation partners are interested in integrating the two disciplines in a more systematic
way and sanitarians and nutritionists using the same language.
Institutional triggering
In 2015 in Bobonaro district Kamal Kar facilitated an institutional triggering that succeeded in engaging
the District Administrator to take the lead around engaging local government (Administrative Post,
Suco, and Aldeia) in mobilizing communities to participate in PAKSI. A road map for ODF Bobonaro
has been developed under the leadership of the administrator and BESIK; UNICEF and World Vision
are supporting the plan on the ground.
CLTS scale
From current data sources (SIBS water and sanitation information system, and SPT Sector Planning Tool)
it is difficult to calculate the number of CLTS triggered communities (aldeia), but it is thought to be more
than 1,000.
ODF success rate

Implementing partners in Timor-Leste estimate that 602 communities are ODF. Reaching ODF takes a
community between two months and one year, with UNICEF reporting 4-9 months.
Indications are that CLTS is having a significant impact on sanitation access and also sustainability of ODF
behaviour. An end-line survey of 55 communities (5,000 families) conducted by UNICEF in December
2014 found a slippage rate of 27 per cent (3-42 per cent reversion). 60 per cent these ODF aldeias
(33 no.) had less than a 10 per cent reversion two to three years after ODF declaration. There had been
a substantial decrease of open defecation by communities in project target areas and moderate
improvement building permanent latrines to move up the sanitation ladder.
All sucos of four sub-districts (two each from Aileu and Ermera) were verified and declared ODF but there
is a reversion of 3-10 per cent. Overall open defecation was reduced from 73 per cent to 9 per cent (Liqui-
doe, Aileu District) and 88 per cent to 3 per cent (Railaco, Emera Disrict).

Baseline KAP 2011 November Endline KAP 2014 December
District
(Average) OD practices by families OD reduced to
Ermera 71% 4%
Aileu 30% 10%
Manatuto 64% 53%
Viqueque 70% 58%
Oecusse 66% 37%
In Alieu district CLTS has been the dominant approach in the municipality since 2010. In 2009,
the sanitation coverage rate for the district was estimated to be 20 per cent, in 2015, the estimated
coverage is at least 85 per cent, even with slippage taken into account.
Successful triggers include: disgust; privacy, convenience, desire for good health and the stigma of
continuing open defecation. BESIK has found some success in triggering around adopting using a toilet
as a new social norm where institutional triggering has been done i.e. Bobonaro.
CLTS capacity
Approximately 200 CLTS facilitators have been trained to date, including 65 who were trained by Kamal
Kar in 2015 and of whom 15 were invited back to a more in-depth training in May 2015 to establish a
PAKSI Quality Control/Support Team for PAKSI implementers in Bobonaro. Of all the trained facilitators
nationwide, about 55 facilitators are still active, including 15 in WaterAid and 20 in UNICEF and five with
Plan and its local NGO partners. Attrition is often due to NGO staff moving to a new unrelated job. A core
group of 10-15 super trainers exists, who are highly competent trainers and CLTS facilitators.
CLTS scorecard
Policy National Basic Sanitation Policy outcome is an open defecation free environment
CLTS in government policy Policy (2012) with ODF sucos being category 1 of 4 levels:
ODF sucos
Hygienic sucos (100 per cent latrine and handwashing
coverage)
Litter free sucos (free of indiscriminate solid waste)
Foul water free sucos (free of wastewater run-off)
The policy allows for household sanitation facilities to be
subsidized where households are disadvantaged (according
to criteria to be set by Ministry of Social Solidarity). ODF
sucos are defined as having excreta-free open spaces,
excreta-free drains, excreta-free water bodies, and
excreta-free institutional buildings.
Strategy MoH Annual Plan No national strategy with targets for achieving ODF
CLTS targets in government communities. MoHs Annual Action Plan includes PAKSI but
strategies or development for institutional support only, with BESIK providing almost all
plans the budget for the achievement of this annual plan.
A draft National Strategic Sanitation Plan was prepared in
2012, which set targets for each of the four categories in the
M&E framework of the National Basic Sanitation Policy. This

draft is currently being revised.
Leadership Some leadership by MoH MoH takes the lead, sets strategies and targets, and is
CLTS led by government responsible for monitoring and verification. However there is
no budget for promoting CLTS. The sector receives consider-
able support from UNICEF and BESIK on strategy develop-
ment, logistics, training, monitoring and verification. NGOs
are implementing under contract to partner agencies.
Finance No government financing at No fund allocated from government budget at the national or
CLTS financed by national or district level district level. BESIK provides budget for sanitation to
government the MoH. MoH has committed to absorb salary costs for
10 Sanitarians in 2016. The National Health Institute has
allocated funds to cover the training of PAKSI trainers
in 2015.

Coordination Sanitation working group CLTS issues are included in sanitation working group
Mechanisms for stakeholder meetings with MoH, DNSB, funders (including BESIK and
coordination UNICEF) and NGOs.

Integration Limited integration Integrated with handwashing, school WASH and with
CLTS integrated with other district level triggering but on a limited scale.
approaches
Triggering Local Facilitation Guidebook MoH PAKSI Facilitation Guidebook includes three modules:
Standardized facilitator Accredited training module Pretriggering, Triggering, and Follow-up and is used by
training implementers. The National Health Institute (INS) has
accredited a 6-day PAKSI Facilitation Training course and
a 10-day Advanced PAKSI Facilitation Training course for
a Quality Control Team. BESIK is helping INS and MoH to
develop workplace-based assessments on the quality of
facilitators and identify further training/mentoring needs.
Facilitator quality control Project checks Currently implementing partners are responsible for their
own quality control through facilitator checks and feedback.
Establishment of a PAKSI Quality Control team, which is
trained to monitor the quality of PAKSI delivery and provide
mentoring support based on identified needs is underway
by MoH. With support from development partners (BESIK,
UNICEF, WaterAid, Plan). The PAKSI Quality Control Team is
composed of sanitation NGO and Government partners.
ODF National ODF Guidelines National ODF guidelines prepared through MoH include:
Clear ODF criteria All households have access to a toilet.
All family members (not including babies) use the toilet.
Water and soap near the toilet for HWWS (not an ODF
criteria in the sanitation policy).
All schools have a working toilet.
The guidelines lack clarity around the definition of family and
household, and whether all households should have toilets
or sharing is permitted. Interpretation of the criteria varies.
Verification protocol No verification protocol There is no harmonized and agreed criteria for ODF
verification and declaration. District BESI team (district
water, sanitation and hygiene (WASH) coordination
committee) involving district level departments of the MoH,
Ministry of Public Works (water and sanitation directorate)
and MoE is responsible for verification. Local NGOs
implementing CLTS facilitate the process and suco and
aldeia leadership also participate. The certification of ODF
is issued by the district public health office. However this
system is not common for all implementing partners. There
is no mechanism to withdraw ODF certification status and
re-verify.
Developing standard operating procedures for ODF
verification and declaration for all sanitation partners is a
priority for the MoH.
Post ODF support No standard approach There is no post-ODF support plan in place, but the need to
have a plan as soon as possible is recognized. Implementers
have different approaches from no follow-up to others such
as WaterAid monitoring ODF villages with six monthly

checks (village checks and meetings, some sample
households) for two years after ODF. BESIK is working with
the MoH, DNSB, and MSS to develop a system for
advancing the sanitation improvement framework, to be
piloted in Bobonaro. Following ODF achievement, ODF must
be sustained for six months before the next level of achieve-
ment is considered.

Technical support Weak product availability A very limited range of sanitation products is readily
Availability of products and and slow uptake of available. Efforts at sanitation marketing have been very
services sanitation marketing slow or not worked so far due to over complexity, small
scale, lack of buy-in from district authorities and weak
enabling environment for triggering and CLTS. BESIK is
working with DFATs Market Development Facility, a private
sector creation/support programme, to increase access to
the sanitation supply at the municipal level and
administrative post level. Progress with this is slow. Other
efforts include World Visions ecosan pilot in Aileu,
small-scale sanitation marketing by local business groups
(and local vendors. UNICEF has implemented a small-scale
business group approach in three districts however it could
not be scaled up due to the high costs of the latrine product
(40 US$ per set) and transportation (30 US$ per set) for
squatting slabs and rings for pit latrines.

Monitoring 1 SIBS: Rural Sanitation No agreed national monitoring systems for ODF monitoring.
Robust and regular Information System ODF data are fed into SIBS (Rural water and sanitation
monitoring of ODF 2 SPT: Sector Planning and information system), run by DNSA/BESIK, but this is not up
achievements Reporting Tool to date. SIBS includes aldeia level monitoring, but field
monitors lack training in ODF definitions and ODF is
inaccurately reported. Input to a Sector Planning Tool
includes annual partner activities and ODF. There have been
some attempts to collect SIBS data through SMS
(electronically), but they have not been successful. In project
areas, implementing agencies manually collect data, and
prepare and submit the monitoring report.
Post ODF monitoring of Very limited Monitoring of ODF sustainability is limited to individual
quality and sustainability implementers. UNICEFs end-line survey report shows some
communities relapsed to open defecation from ODF status
but the reasons for slippage are yet to be identified.
Evaluations and Limited recent learning Limited shared learning and evaluations on CLTS.
knowledge sharing UNICEF KAP baseline 2011/end-line 2014 study in
Evaluations, reviews and 55 aldeias highlights ODF sustainability (e.g. just
learning 4 per cent slippage in two subdistricts in Emera).
CVTL 2014 learning study on sanitation reports that the
subsidy method is better than CLTS because sanitation is
more sustainable, however this is at household level and
not ODF communities. The selection of communities was
done by CVTL and independence may be compromized.
MoH wants to have an impact evaluation of CLTS in the
near future, possibly using a recent Plan study
methodology.
The sector lacks a common strategic approach.
Information on costs and No standard costs There are no standard costs for reaching ODF in
resources for CLTS communities, although partners believe this could be a
worthwhile pilot for the future in order to know the level
of effort and cost to scale up. UNICEF estimates the cost
of achieving ODF, including verification, is US$ 800-1,200
per aldeia (or community) of 60 families (i.e. about US$
13-20 per family), based on NGO contracts. UNICEF
overhead costs are not included.

MoH estimates approximately US$ 12,500/suco (4-5
aldeais per suco) to contract an NGO to implement PAKSI.
This does not include the cost of sub-district Sanitarians.

1 New types of triggering Institutional triggering has been introduced to motivate district authorities and to increase
awareness on sanitation issues. In Bobonaro this is showing positive signs.
Separate triggering sessions with children have been tried and are showing influence on
parents.
2 Improved facilitation skills Facilitator skills have been improved through training, particularly focusing on pre and post trig-
gering. Five batches of trainings to improve facilitations skills involving 200 facilitators have been
held, with three of these trainings facilitated by Dr. Kamal Kar and his associates from CLTS
Foundation.
3 Improved coordination Improved coordination among CLTS implementing agencies. This has been achieved through
implementation of five joint training of facilitators. Partners are also doing joint planning for
achieving ODF in Bobonaro district, and this process has potential to be expanded to other
districts.
4 Greater acceptance of CLTS (PAKSI) is gaining acceptance and popularity among the district authorities and
CLTS communities; e.g. communities and authorities have started using the term tae (meaning
faeces in the local language).
Lessons learned
1 Government leadership is CLTS is still INGO and UNICEF-led, and government, especially MoH, is highly dependent on
needed to scale up donors. Without Governments strong commitments, especially from the decision makers, it will
be difficult to expand CLTS nationwide. There is a need for government to allocate dedicated
budget for monitoring and follow-up of CLTS activities with adequate human resources in the
Environmental Health Department (EHD) of MoH. Without a strong, committed and equipped
EHD, CLTS cannot be led effectively by EHD.
2 Subsidies undermine Household subsidy is still practised by CVTL which works in many communities across number
CLTS of districts and undermines CLTS to some extent. The modality of subsidy by CVTL needs to be
changed (it could be an incentive to move up the sanitation ladder after ODF).
3 Sector actors need There is no comprehensive common understanding or analysis of the rural sanitation sector yet
common understandings and no common path forward. Implementing partners see parts of the problems and solutions
and goals but there is a need for everyone to join hands to remove the bottleneck and barriers in a
synchronized manner. There is no costed strategy (or action plan/road map) for sanitation with a
clear target of ODF for Timor-Leste by a target date. Agencies and partners are still talking about
sanitation for all by 2030 (as per Governments Strategic Plan 2011-2030), however this target
is very ambiguous and farsighted. An interim target of ODF Timor-Leste is needed much earlier
than 2030 to drive action and resource allocation. All partners need to use the same approach.
4 Pre-triggering of More effort is needed on institutional triggering as this has been neglected in the past. By
government institutions engaging municipal administrators this connects through line responsibility down to suco
can unlock doors chiefs and is a way of opening doors to lower levels of government. More work is needed on
identifying and accessing the entry points to local government (sub-district and suco level)
decision-making meetings and how CLTS can be introduced at the pre-triggering phase. From
Bobonaro it was found that working with suco councils rather than just suco chiefs gives access
to two womens representatives and a youth representative who can support sanitation in their
communities more effectively than just relying on aldeia chiefs.

1 Capacity of facilitators Lack of skilled and committed facilitators is still a major problem.
2 Few CLTS implementers Lack of partners due to funding uncertainty for CLTS activities. Only few international agencies
(e.g. UNICEF, Plan and WaterAid) are committing to expanding CLTS in their project districts.
There is no firm commitment from Government to fill the coverage gap (no funds set aside from
Government for scaling-up CLTS activities).
3 Weak monitoring Limited monitoring from the Government for CLTS activities implemented by international
agencies (INGOS, UNICEF etc.). Lack of follow-up plan after ODF for supporting communities
to sustain the behaviour. No overall reliable database for assessing progress and sustainability.
There is a need to take stock of what has been achieved in districts since the start of CLTS
to learn from successes and failures, and improve SIBS so that it can be better used as a tool
for monitoring.
4 Mindset on subsidies Some of the key DNSA staff (and other Government e.g. ministers/vice ministers) see CLTS
toilets as inferior and that subsidies are needed with sanitation marketing. A change in mindset
of government as well as some implementers is needed.
5 Lack of integrated There is no integrated approach with all the elements in place needed to make CLTS work e.g.,
approach strategy and targets, product availability, institutional buy-in, and Behaviour Change
Communications. The enabling environment is not in place and no analysis has been done on
what is required e.g. bottleneck analysis.
6 Weak information The sector is lacking in joint analysis, reflection, and problem solving on CLTS. A common
understanding of barriers and the way forward does not exist. The known enablers are not
identified why have some aldeias become ODF and stayed that way? The learning of
successes is not being captured.

1 Integrating CLTS and Timor-Leste has the highest under five stunting rate (50.2 per cent). The Government of
nutrition Timor-Leste and some funding agencies (e.g. EU) are working together to improve its nutrition
status. There is a window of opportunity to advocate a link between malnutrition, poor sanitation
and hygiene (especially open defecation) and garner support for sanitation (CLTS) as a
pre-requisite for improving the nutrition status among children. Donor agencies are doing this
but have not been able to convince the Government to allocate funds for sanitation yet. There is
a need for additional work in this area.
2 Institutional structure Supportive institutional set-up. Government structures run all the way down to the aldeia level,
with each level having an elected representative. If the national authority gives adequate support
and direction, expanding CLTS should not be a major problem.
3 Small size of country Timor-Leste is a small country, and all villages are accessible within a few hours travel from the
district headquarters. This has advantages for the spread of information and materials which
needs to be capitalized on.

VANUATU
VANUATU: Country CLTS overview
Rural sanitation
2012 2015
100 2 2
Status and CLTS date of introduction Not yet Not yet
scale
CLTS spread: % of country
90
CLTS in urban areas
CLTS coverage: major organizations 80
28

Villages triggered (number) 70
ODF villages (number)
Capacity developed (trained facilitators) 60 15

50
CLTS financed by government No No 10
40
30
Effectiveness ODF success rate 55
20 38
10
2012
Open defecation 2% 796 3,899 3,560 2000 2015

Shared sanitation

The JMP estimate suggests a recent increase in improved sanitation coverage in rural areas of Vanuatu
from a baseline of 32 per cent in 1995 to 38 per cent in 2010, and 55 per cent in 2015. Currently
43 per cent of the rural population use either shared sanitation facilities or unimproved facilities. The open
defecation rate was estimated to be only 2 per cent, and is unchanged since the last review in 2012. This
suggests that fewer than 800 rural households (3,900 people) do not use any form of
sanitation facility.
Recent data suggest Vanuatu is expected to meet its MDG7 target for sanitation sometime in the
2016-2020 period, just missing the sanitation MDG in 2015.21 The rural sanitation MDG will just be met,
while for urban areas, access to improved sanitation has decreased in recent years.
Sanitation facilities were also damaged or destroyed following Cyclone Pam in 2015.

CLTS has not been introduced into Vanuatu.
21 ADB, Key Indicators for Asia and the Pacific 2014, p116 http://www.adb.org/sites/default/files/publication/43030/ki2014-mdg7.pdf

In 2013 UNICEF initiated possible twinning within the Pacific by sponsoring three participants from
Vanuatu (UNICEF, MoH, and a rural training centre representative) to participate in CLTS training by
Kamal Kar in the Solomon Islands. All participants were PHAST trainers and saw the potential of CLTS as
an approach, however no national trainings have been held due to the limited applicability of CLTS to the
sanitation situation in Vanuatu.
With very low rates of rural open defecation CLTS is not seen as a suitable approach for Vanuatu and the
preferred focus is on upgrading from unimproved sanitation (including open pits and shared facilities) to
improved sanitation by climbing the sanitation ladder. Other methods such as sanitation marketing and
PHAST are considered more applicable.
Institutional setting
The MoH has responsibility for rural sanitation with support of the Department of Geology, Mines and
Water Resources. Urban sanitation is the responsibility of municipal authorities.
The MoHs National Environmental Health Policy and Strategy 2012-2016 includes water, hygiene and
sanitation as one of its core health prevention strategies, specifically aimed at MDG7 for increasing
access to improved sanitation. The strategy has a goal of 80 per cent of the rural population having ac-
cess to improved sanitation by 2016. The strategy to achieve this is by developing national sanitation stan-
dards (VIP, water seals, water tanks, compost toilets, and septic tanks), and improving sanitation facilities
in communities, schools and health facilities. The Healthy Islands approach is mentioned as one possible
way to achieve the strategy. Communication approaches include developing IEC materials on sanitation,
training Environmental Health Officers on WASH and National Sanitation Standards, and
introducing the sanitation standards to communities. Although there is now more focus on behaviour
change, the current strategy lacks detail on how to implement this and MoH needs to develop a
standardized module of what effective hygiene promotion and behaviour change communication entails
in order to standardize the approach across the country.
Major exceptions
1 Subsidies
While there is greater recognition of the cost of latrine subsidy programmes in Pacific island states
and their failure at sustaining improved sanitation (the majority of subsidized latrines fall into disuse
and disrepair after only a few years), subsidized models are still taking place in forms of bags of
cement, or other sanitation components.
Some NGOs and church organizations still subsidize sanitation in some form. For example the Anglican
Church of Melanesia with support from ABM is working with churches in Vanuatu to deliver clean water
and hygienic toilet facilities to people in rural areas. This WASH project includes installation of Ventilation
Improved Pit toilets (or VIP toilets) in schools, parishes and communities. Staff from the Anglican Church
of Melanesia are training local youth in VIP toilet installation.
Live and Learn has developed an approach that combines sanitation marketing with PHAST and some
elements of CLTS, although this is being implemented on a limited scale.

VIET NAM
VIET NAM: Country CLTS overview
Rural sanitation
2012 2015
100 1
scale
90 25
25
Villages triggered (number) 829 2,025 70 4

Capacity developed (trained facilitators) 1,132 2,073 60
Enabling CLTS in government policy May be Yes

50 3
CLTS financed by government May be Yes
40
CLTS sustainable monitoring No Yes 70
30
Effectiveness ODF success rate 17% 27% 47
20
10
2012
Open defecation 1% 155,037 620,150 3,669,700 2000 2015
Shared sanitation facilities 4% 620,150 2,480,598 2,446,400 Unimproved sanitation

Shared sanitation

The JMP estimate suggests a rapid increase in improved sanitation coverage in rural areas from a
baseline of 30 per cent in 1990 to 70 per cent in 2015. This is an impressive increase in improved
sanitation coverage of 48 per cent in the last 15 years alone. According to the JMP open defecation has
reduced from 43 per cent in 1990, to 25 per cent in 2000 and just 1 per cent in 2015. While there has
been a significant decrease in open defecation this figure is somewhat misleading as it excludes fish
pond latrines and other hanging latrines over rivers, which the Government of Viet Nam defines as
unimproved latrines, rather than fixed point open defecation. From the JMP there are an estimated
155,000 rural households (620,000 people) who do not use sanitation facilities, but if fixed point open
defecation is included then this number will be higher.

Introduced by SNV in 2008. CLTS has since spread to 20 out of 64 provinces in Viet Nam (31 per cent
nationally) in 2015, although in most provinces only selected districts are supported representing about
15 per cent of the country. Selection of areas for implementation is based on high rates of open
defecation, low rate of households with hygienic latrines and ethnic minority areas. With an upcoming
World Bank/GOV Payments for Results loan programme Scaling Up Rural Sanitation and Water Supply
(SupRSWS) support will increase through targeting of 19 of the countrys poorest provinces located in
the Northern Mountains and Central Highlands regions.

Farmers
Association EMW
WU, YU Plan UNICEF Ministry of Health
VIHEMA
World
Vision
Codespa
Codespa
Codespa MAJOR EXCEPTIONS
Subsidy programme
Provincial government
CHOBA
NGOs
The Vietnam Health and Environment Management Agency (VIHEMA) of the Ministry of Health is the
lead agency for sanitation and a major implementer through seven UNICEF focus provinces and five Plan
International supported provinces. VIHEMA provides training materials, low cost latrine designs, and
guidelines for CLTS and sanitation marketing. Provincial Centres for Preventative Medicine support
facilitator training in these provinces. World Vision is implementing CLTS in nine provinces, with
Codespa and Child Fund also having a lead role. Child Fund has implemented CLTS in a total of 19 com-
munes in two northern provinces since 2010. Church World Service (CWS) is implementing in three
districts in Lai Chau and Thai Nguyen provinces. Several Viet Nam mass organizations such as Famers
Association, Womens Union, Youth Union are also engaged in CLTS.
World Vision implements CLTS in peri-urban areas in Hung Yen province.
UNICEF has been instrumental in introducing CLTS within the provincial and national government
systems through the DOH and MOH. This has largely helped CLTS as an official strategy for promoting
sanitation. UNICEF has also introduced CLTS into the Government of Viet Nams Rural Water Supply and
Sanitation National Target Programs.
Major exceptions
Government
Over time, VIHEMA, as the practicing lead agency for sanitation is increasingly convinced the use of
CLTS, SLTS and Sanitation Marketing is the way forward for sanitation promotion in Viet Nam.
Previously subsidies were understood to be the way forward but the current understanding is on
promoting more investment in community mobilization, follow up monitoring and leadership
development. Some provinces are continuing to support subsidies for lowest income quintile
households.
East Meets West (EMW) Community Hygiene Output Based Aid (CHOBA)
EMW uses CLTS as the approach to sanitation promotion but the CHOBA programme also
encourages households to build improved household sanitation facilities and connect them with both
approved local construction contractors and consumer lenders. Poor households are offered a
consumer rebate (equivalent to 5-10 per cent of latrine cost) upon verification of a properly built and
used toilet. Poor households must pre-finance the full latrine cost before receiving the rebate.
Financial rewards are offered for the achievement of community-wide improved sanitation coverage
benchmarks.
Church World Service:
CWS supports 30 per cent of the cost of latrine construction in Muong Te District in Lai Chau
province. This is a very remote mountainous area in the northwest of Viet Nam, where many poor
ethnic minority tribes live. Some communities have deeply entrenched traditional sanitation
behaviours. In other districts CWS does not support any hardware costs.

CLTS is being integrated into:
Rural Water Supply and Sanitation Program National Target Program (NTP), National Patriotic Sanitation
Movement; hand washing and sanitation marketing; and a Village Saving Loan programme of Plan
International.
1 ChildFund: CLTS + PHAST
ChildFund is integrating CLTS with PHAST tools in order to provide knowledge about the relationship
between hygiene and health as well as to enhance hand washing with soap practice and hygienic
water usage. In order to raise the rate of households having hygienic latrines, activity will be
combined with saving credits in the livelihood sector to improve economic conditions at the
commune, with health sector to prevent malnutrition and water and environment sanitation related
diseases. In addition, projects have conducted SLTS, CHAST, and activities advocating hand washing
with soap at school.
2 SNV: Sustainable Sanitation and Hygiene for All (SSH4A)
SNV is implementing the SSH4A programme in five countries (Viet Nam, Lao PDR, Cambodia, Nepal
and Bhutan). In Viet Nam, the SSH4A programme targets poor, ethnically diverse villages in the
Northwest, using CLTS with additional components to provide information on sanitation options,
behaviour change communication, increase access to low-cost sanitation goods and services, and
improve WASH governance.
3 Plan International: Sanitation Marketing
Plan WASH combines CLTS triggering of villages to stop open defecation (OD) with the introduction
of low cost options for sanitation (under Sanmark) to encourage people to make and use hygienic
toilets (particularly pour flush toilets using concrete rings that can be made on-site using a mould from
galvanized iron).
4 MoH and UNICEF: Community Approaches to Total Sanitation (CATS)
In Viet Nam, CATS is being implemented using interventions on CLTS, School Led Total Sanitation
(SLTS), sanitation marketing and hand washing with soap. Supply chains and sanitation markets in the
project areas are strengthened to meet and maintain the sanitation demand triggered by CLTS, and
hand washing with soap is included to ensure that this critical faecal-oral disease transmission route
is blocked.
CLTS capacity
Large numbers of CLTS facilitators have been trained in Viet Nam. Codespa reports that 700 CLTS
facilitators have been trained under its programmes. The Ministry of Health and UNICEF have also
supported the training of 900 CLTS facilitators, World Vision 250, Plan International 150, and ChildFund
73, making a total of 2,073 facilitators trained. Of these only 15 per cent are estimated to still be active.
CLTS scale
More than 2,020 villages have now been triggered using the CLTS approach, with the Ministry of Health
efforts accounting for nearly 40 per cent of these triggered villages.
ODF success rate

CLTS is thought to be one of the most effective community mobilization models in sanitation promotion,
and has resulted in a reduction of OD, and increased latrine coverage. Viet Nams ODF success rate has
improved from 17 per cent in 2012 to 27 per cent in 2015. The number of certified ODF villages reported
is 120 for MOH; Plan International reported 188 including self declared villages without formal
certification; 63 villages by Codespa, ChildFund 62, and World Vision has not yet conducted an
assessment of the ODF villages. At least 468 villages are ODF which is just xx per cent of the villages
triggered to date or between 15-69 per cent rate depending on the implementer. Time required to reach
ODF is between six to 12 months depending on the location.

CLTS scorecard
Policy 1 National Target Program 1 CLTS included in the NTPIIIs sanitation planning and
CLTS in government policy RWSS III Phase implementation guidelines as an acceptable approach.
2012-2015 Decision 366 Toilets are a household responsibility. Focus on
2 Patriotic Sanitation sanitation targets, particularly household latrines with
Movement priority to low-cost models and preferential credit to
improve the access of the poor Shift from IEC for
3 VIHEMA (2013) National awareness improvement to IEC for behavior changes.
Guideline for Planning and
Implementation on Rural 2 The Patriotic Sanitation Movement being implemented in
Sanitation 30 provinces is designed to promote better sanitation in
schools and the community and encourages communities
to adopt hygienic habits and use toilets.
3 VIHEMA guidelines include creation of collective
demand for rural sanitation, such as community
approaches (e.g. Community-Led Total Sanitation (CLTS).
Strategy 1 Resolution No. 05/NQ-CP 1 Resolution No 5 for promoting MDGs achievements,
CLTS targets in government dated 01/13/2014 hygiene and sanitation targets.
strategies or development 2 Draft 5 year sanitation 2 The Government has a commitment for achieving
plans plan 2016-2020 85 per cent of hygienic toilets by 2020, with the draft
3 Provincial plans 5-year sanitation plan 2016-2020 including annual targets
and roadmaps for ODF by 2025. The draft 5-year
sanitation plan includes capacity building in sanitation for
the health system.
3 CLTS is included in provincial sanitation plans in provinces
with high rate of OD.
Leadership Ministry of Health The Government, through the MoH VIHEMA is taking full
CLTS led by government leadership of CLTS implementation at the national level,
including developing guidelines, training etc. Centres for
Preventative Medicine have responsibility at province level.
Finance Limited government budget Government provides a modest budget mainly for training
CLTS financed by and communication activities.
government
Coordination Sanitation Working Group Annual review of CLTS included as part of sanitation working
Mechanisms for stakeholder group under the leadership of VIHEMA and supported by
coordination UNICEF.

Integration Integrated at programme Rural National Target Program
CLTS integrated with other and project level National Patriotic Sanitation Movement
approaches Hand washing
Sanitation marketing
Village Saving Loan programme (Plan International)
Integrated with PHAST tools to enhance hand washing
with soap practice and hygienic water usage, saving
credits in the livelihood sector, prevention of malnutrition
and water and environment sanitation related diseases,
SLTS (ChildFund)
Triggering MoH facilitator training Standard CLTS training manual and supporting materials
Standardized facilitator developed by MoH and used by implementers for training.
training The College of Agriculture and Rural Development is a

centre for CLTS master training. A database of CLTS master
trainers is maintained.
Facilitator quality control Programme based Method for facilitator quality dependent on implementing
agencies. Quality is checked through on the job feedback, re-
flection and checklists by NGOs; with some monitoring and
evaluation by provincial Centres for Preventive
Medicine. No standard approach, or accreditation.

ODF Comprehensive ODF1 and Criteria developed by MOH and tested with stakeholders in
Clear ODF criteria ODF2 criteria developed by seven provinces. Not yet nationally endorsed but criteria is
MoH and tested comprehensive. Two stages: ODF1 includes all household
members use latrines and safely dispose of children faeces,
no traces of faeces in open places; at least 90 per cent
households have latrines; 10 per cent households share
latrines with others; 70 per cent of households have hand
washing places with cleaning substance; community
resolution on sanitation to stop OD and use hygienic
latrines; community monitoring group established. ODF2
includes 90 per cent of households with hand washing and
greater use of hygienic latrines. Criteria for commune and
district ODF level 1 and 2 also established which includes
WASH facilities in schools and health centres with a
maintenance budget. ODF certification can be withdrawn at
all levels if spot checks by health staff show violation of ODF
criteria.
Verification protocol MoH protocol developed Verification and certification protocol for village, commune
and tested and district level developed by MoH with technical
assistance from UNICEF. Protocol has clear responsibilities
and timeframes. Tested in seven provinces and being
reviewed after feedback. Not yet nationally endorsed.
Post ODF support Some post ODF Post ODF support includes on-going monitoring and in
reinforcement the MoH provinces, the ODF and latrine status is checked
every six months. Follow-up contact occurs through later
implementation of School-Led Total Sanitation and sanitation
marketing in ODF villages. Post ODF follow-up is occurring
but is not consistent across all implementers or
systematically carried out.
Technical support Sanitation marketing Most implementers introduce sanitation marketing through
Availability of products and an informed choice of options to provide information for
services people. Some NGOs such as Plan International introduce
sanitation marketing 6 months after triggering; others
introduce immediately after triggering. Informed choice
includes low cost technical options e.g. mould for concrete
rings and toilet pan, sanitation marketing tools and
guidelines. The poorest of the poor generally continued to
face difficulties getting onto the sanitation ladder; better off
move from pit latrine to pour flush. Product availability is the
most difficult in northern mountainous areas.
Monitoring Reporting protocols Robust monitoring system developed at village, commune,
Robust and regular district and province levels with reporting time frames.
monitoring of ODF Management board of each level is responsible for planning,
achievements monitoring and synthesizing the plan for ODF verification
and certification at their respective level. The monitoring plan
is approved together with the implementation plan for ODF
verification and certification. Village level monitoring and
reporting each month. Provincial reporting to VIHEMA annu-
ally. The current national monitoring system focuses on HH
latrine coverage only and there is no formal national system
for tracking CLTS progress or performance. ODF monitoring
will be introduced in the new guideline for

2015-2025. Manual recording with computerized data entry.
Post ODF monitoring of Draft guidelines for MoH has guidelines for monitoring sustainability. Spot
quality and sustainability sustainability checks checks are carried out. The Qualitative Assessment of
Sanitation study found HHs that used a latrine as a result of
CLTS kept up this behaviour, if the latrine was in good repair,
but sustainability proved a challenge where HHs primarily
responded to CLTS by building simple pit and VIP latrines.

Evaluations and Some reviews of CLTS Viet Nam has conducted several reviews and evaluations on
knowledge sharing CLTS:
Evaluations, reviews and National review in 5 provinces 2011 (VIHEMA&UNICEF)
learning Regional review of CLTS in 2012
National Qualitative Assessment study in 10 provinces
including CLTS assessment 2013 (VIHEMA&WSP)
Provincial assessment in Quang Ngai 2013 (Plan
International)
Slippage not studied in detail but there is an understanding
that some households built latrines but do not use them.
Reasons are: ODF is not a social norm yet, weak leadership,
lack of commitment, lack of water supply, temporary toilets,
lack of regular follow-up.
Reviews and assessments have been consulted and
disseminated among relevant stakeholders at national and
local levels.
Information on costs and Qualitative Assessment of Detailed costs per village are not available or benchmarked.
resources for CLTS Programmatic Approaches The Qualitative Assessment of Programmatic Approaches
to Sanitation to Sanitation in Viet Nam was conducted in 10 provinces
by VIHEMA/WSP. The assessment shows that the cost of
CLTS per commune irrespective of commune size varies
widely from US$ 1,500-50,000.

1 ODF verification and Previously there was no official guide on what constitutes ODF and how to verify and certify
certification guidelines when this milestone was reached. The introduction of ODF verification and certification
guidelines has resulted in a commonly understood and clear definition of the ODF verification
process. The guidelines comprehensively deal with faecal sludge management, as well as at
commune level, bringing schools and health centres into the formalized certification process. The
guidelines have been carefully developed and tested, with input from stakeholders.
Lessons learned
1 Government commitment CLTS is given more attention and support when the Government commits to becoming ODF by
needed for scaling up 2025 with a detailed plan and roadmap developed to reach this target, World Bank loan project
for the scaling up of sanitation is upcoming and CLTS is mainstreamed into the poverty
alleviation programmes.
2 Quality of triggering The quality of facilitators impacts the quality and effectiveness of triggering sessions, with con-
sistent quality follow-up needed to reach and sustain ODF. Implementing organizations do review
facilitator performance at triggering and usually provide support and monitoring of
facilitators but this is not systematic and varies between organization. Ensuring quality of follow
up is a challenge.
3 Link with sanitation CLTS must be implemented together with sanitation marketing to address both supply support
marketing and demand creation. The availability of low-cost, socio-culturally appropriate latrine options
using locally available materials has helped increase sanitation for a wider range of people with
different levels of affordability and make CLTS more effective. Having markets available for
sanitation products and services is important, as is involving masons early in the process.
4 Localize Viet Nams recent experience highlights the importance of using local language (especially for
ethnic minority areas) for triggering and other communications. The involvement of opinion
leaders/religious leaders within communities can shape attitudes and change behaviour,
however the commitment of local leaders is a critical factor in sustaining behaviour change.
5 Cost efficiencies The cost of implementing CLTS in a country the size of Viet Nam is expensive and the
Government has little budget. Ways to minimize costs include: applying a district-wide approach
to get economies of scale and increase ODF results; combining monitoring with other activities
and village visits; optimizing facilitator training.

1 Ability of poor After triggering, some households do not build latrines, including entry level basic latrines,
because they lack money. In some poor areas, the breadwinners of households work away from
home, leaving only elderly people and children at home, making it difficult for poor households to
physically dig pits and build latrines. There is little evidence of community initiatives to
support the poorest members to build a latrine.
2 Weak capacity at village Village heads promote triggering, which means that the activeness of these people affects the
level triggering quality. Womens Union members at village level appear unenthusiastic and unskilled
even though they have been trained frequently.
3 Poor follow-up at district Currently the district Government is tasked to provide management support to CTS
level implementation e.g. triggering, monitoring, and encouragement. However it is difficult for
district staff to regularly provide support due to other commitments and distance to
communities. The appointment of staff at the commune level to lead and monitor would
increase efficiency of CLTS implementation.
4 Latrine solutions for There is still a gap in the availability of lowest cost latrine models that are suitable for hilly areas
challenging environments and the social and cultural conditions of some communes.

1 Governments Strong Government commitment to ODF by 2025, with a large loan programme from World
commitment of ODF Bank on scaling up sanitation with matching funds from the Government.
by 2025
2 National ODF Guideline National ODF Guidelines have been drafted, and when issued by MoH will become the standard
for everyone to follow, especially guiding the responsibilities of local governments. The
guidelines will also put emphasis on achieving and sustaining ODF rather than building toilets.
3 Low cost latrine options Low cost latrine options are being developed by the MoH. Once issued they will provide official
guidance on ranges of latrines including low cost hygienic latrines.

ANNEX 2: COUNTRY REVIEW
TEAMS AND OTHER CONTRIBUTORS
List of the key stakeholders involved or consulted in the preparation of the country CLTS overviews.
COUNTRY ORGANIZATION NAME POSITION EMAIL
Cambodia Plan Hang Hybunna WASH Specialist Hybunna.hang@
plan-international.org
SNV Petra Rautavuoma WASH Sector Leader PRautavuoma@snvworld.org
UNICEF Kabuka Banda Interim Chief WASH kbanda@unicef.org
UNICEF Santepheap Heng WASH Officer sheng@unicef.org
WaterAid James Wicken Country Representative James.wicken@wateraid.org.au
WSP Phyrum Kov Country Coordinator pkov@worldbank.org
WSP Virak Chan WASH Officer vchan1@worldbank.org
China UNICEF Zhenbo Yang Chief WASH zyang@unicef.org
DPR Korea UNICEF Kabuka Banda Chief WASH kbanda@unicef.org
Indonesia Plan Budi Suranto WASH Specialist Budi.suranto@plan-
international.org
UNICEF Aidan Cronin Chief WASH acronin@unicef.org
WSP Devi Setiawan Country Coordinator dsetiawan@worldbank.org
Kiribati UNICEF Beia Tiim Community Development btiim@unicef.org
Officer
KIRIWATSAN Pauline Komolong WASH Adviser paulinek@spc.int
Program
Lao PDR Plan Ketsadasak Kiettisak WASH Program Manager Ketsadasak.kiettisak@plan-
international.org
UNICEF Bishnu Timilsina Chief WASH btimilsina@unicef.org
WSP Viengsamay Vongkhamsao Country Coordinator vvongkhamsao@worldbank.org
WSP Bounthavong Sourisak Sanitation Specialist bsourisak@worldbank.org
Mongolia UNICEF Batnasan Nyamsuren WASH Officer bnyamsuren@unicef.org
Myanmar Plan Theitdi Thein WASH Program Manager Theitdi.Thein@plan-
international.org
PART II ANNEX 2: Country review teams and other contributors
UNICEF Bishnu Pokhrel Chief WASH bpokhrel@unicef.org

UNICEF Theingi Soe WASH Specialist thsoe@unicef.org
Papua New UNICEF Kencho Namgyal WASH Specialist knamgyal@unicef.org
Guinea
WaterAid Rick Steele Country Representative rick.steele@wateraid.com.au
WaterAid Norma Sagom Health Advocacy Advisor norma.sagom@wateraid.org.au
WSP Trevor Nott WASH Consultant trnott@googlemail.com
The WSP Leo de Castro WASH Consultant leopdecastro@gmail.com
Philippines
Marie Toperez marietoperez@yahoo.com
Bernadette Undangan berndet29.jd@gmail.com
Plan Edgar Viterbo Program Advisor Edgar.viterbo@plan-
international.org
UNICEF Sam Treglown WASH Officer streglown@unicef.org
UNICEF Louise Maule WASH Chief lmaule@unicef.org
WSP Edkarl Galing Country Coordinator egaling@worldbank.org

COUNTRY ORGANIZATION NAME POSITION EMAIL
Regional Plan Hilda Winartasaputra Regional WASH Specialist Hilda.winartasaputra@plan-
international.org
UNICEF Chander Badloe Regional WASH Adviser cbadloe@unicef.org
WSP Susana Smets Senior Regional Water ssmets@worldbank.org
Supply and Sanitation
Specialist
UNICEF (Fiji) Marc Overmars WASH Chief Pacific movermars@unicef.org
UNICEF (Fiji) Brooke Yamakoshi WASH Specialist byamakoshi@unicef.org
Solomon UNICEF Donald Burgess WASH Specialist dburgess@unicef.org
Islands
UNICEF Godwin Kamtukule gkamtukule@unicef.org
WaterAid Amy Dysart Country Representative amy.dysart@wateraid.org.au
Timor-Leste Plan John McGown WASH Program Manager John.mcGown@plan-
international.org
UNICEF Ramesh Bhusal Chief WASH rbhusal@unicef.org
WaterAid Alex Grumbley Country Representative alex.grumbley@wateraid.org.au
BESIK Heather Moran Behaviour Change Heather.Moran@besiktimor.org
Communication Advisor
BESIK Michelle Whalen M&E Advisor michelle.whalen@besiktimor.
org
BESIK Ansye Sopacua Sanitation Adviser asopacua@gmail.com
Vanuatu UNICEF Hilson Toaliu WASH Officer htoaliu@unicef.org
UNICEF Brecht Mommen WASH Adviser bmommen@unicef.org
Viet Nam Plan Nguyen Quy Hoa WASH Program Manager Hoa.nguyenquy@plan-
international.org
UNICEF Lalit Patra WASH Team Leader lpatra@unicef.org
UNICEF Nguyen Thanh Hien WASH Officer nthien@unicef.org
UNICEF Tran Thu An WASH Officer ttan@unicef.org
WSP Nguyen Quang Vinh Senior Water and vnguyen2@worldbank.org
Sanitation Specialist
WSP Nguyen Diem Hang Water and Sanitation hnguyen10@worldbank.org
Specialist
WSP Minh Thi Hien Nguyen Hygiene Specialist mnguyen1@worldbank.org
In addition, many people assisted with providing information for case studies. Some of those are:
PART II ANNEX 2: Country review teams and other contributors
Gavin Gramstad and Kristine Wager (Samaritans Purse, the Philippines); Michael Gnilo (UNICEF HQ);
Simone Klawitter (UNICEF, Tacloban); Wendy Sarasdyani (WSP Indonesia); Anne Joselin, Melinda Hutapea
(DFAT Indonesia); Louis OBrien, Lutz Kleeberg; Ika Francisca (IUWASH Indonesia); Wildan Setiabudi;
Ermi Ndoen; Muhammad Zainal, Muhammad Kurniawan (UNICEF Indonesia).

PART II ANNEX 3: Data from regional CLTS review
140
ANNEX 3: DATA FROM REGIONAL CLTS REVIEW

Table A3.1 Key indicators from country CLTS overviews (2012 and 2015)
% % ODF ODF
SPREAD SPREAD OD POPN OD POPN TRIGGERED TRIGGERED ODF ODF SUCCESS SUCCESS
COUNTRY INTRO DATE 2012 2015 2012 2015 2012 2015 2012 2015 2012 2015
Cambodia 2004 48 76 8,132,400 7,457,002 1502 6160 608 1,494 40% 24%
China 2012 15 15 13,483,000 12,442160 0 50 0 31 0% N/A
Indonesia 2005 97 100 38,322,880 34,303,67 7,325 24,955 1,279 4,419 17% 18%
Kiribati 2012 0 48 29,128 28,807 0 135 0 103 0% 76%
Lao PDR 2008 47 59 1,698,600 1,594,361 217 565 36 144 17% 25%
Mongolia 2011 0 24 272,200 220,663 10 N/A 1 0 10% N/A
Myanmar 2010 12 29 2,546,000 2,141,715 224 531 12 63 5% 12%
Papua New Guinea 2008 95 86 1,079,800 863,107 477 666 21 144 1% 18%
The Philippines 2008 10 18 5,718,300 5,663,003 211 677 36 473 17% 70%
Solomon Islands 2012 10 44 143,700 299,624 2 50 0 0 0% 0%
Timor-Leste 2007 100 100 269,400 283,818 761 1,000 262 602 34% 60%
Viet Nam 2008 29 31 3,669,700 620,150 829 2,025 145 471 17% 27%
ANNEX 4: CASE STUDIES
1. Cambodia: Which comes first: CLTS or sanitation marketing?
2. Indonesia: CLTS in Indonesias decentralized context: At what level

is support most effective for scaling up sanitation?
3. Indonesia: Adapting CLTS for a major urban WASH programme in

Indonesia
4. Kiribati: No golden solution ODF is easy but sustainability it is hard

in Kiribatis challenging environment
5. Myanmar: Myanmar Doing the ODF two-step
6. Philippines: Closing the gap Using CLTS to fast track sanitation for
the poor in the Philippines
7. Philippines: CLTS in post emergency situations Philippines
8. Solomon Islands: CLTS in urban areas: Informal settlements in the

Solomon Islands
9. Viet Nam: Case study Testing Viet Nams ODF criteria and
certification process
PART II ANNEX 4: Case studies

CAMBODIA

Cambodia: Which comes first: CLTS or sanitation marketing?
Is there a best way to integrate sanitation marketing with CLTS? Which should come first sanitation
marketing or CLTS? Cambodia has years of experience in implementing both sanitation marketing and
CLTS. This case study looks closely at the different approaches used in Cambodia and draws conclusions
on how CLTS and sanitation marketing best work together.
Defining sanitation marketing
According to the Water and Sanitation Program (WSP), sanitation marketing:
.is an approach that aims to increase demand for sanitation and to strengthen private sector
capacity to supply sanitation products and services. The focus on the private sector and a view of
households as consumers rather than beneficiaries is what sets sanitation marketing apart from
conventional approaches to sanitation service provision.
Sanitation marketing focuses on the development of the sanitation market place, increasing
demand for sanitation while simultaneously expanding market-based supply of sanitation products
and services for low income households.
For Cambodia, this definition simplifies what is happening in practice. International NGO iDE and local
NGO WaterSHED work with private businesses to develop production and sales capacity, in keeping with
the WSP definition of sanitation marketing. However, there are variations to this approach: the World
Toilet Organization (WTO) implements a franchise model where masons are supported and linked with
a centralized production centre for the bulk production of slabs, lid covers, and chamber boxes; Plan
International is building sanitation businesses with groups of young school drop outs; Live and Learn
works with local communities through a mobilization approach rather than a private sector market-based
approach. All of these approaches are called sanitation marketing in Cambodia.
As Petra Rautavuoma of SNV Cambodia says, Its important to recognize that we use the same term
sanitation marketing but what we do under the term can be quite different.
According to WSP: Sanitation marketing is about more than just training masons. It involves a more
comprehensive demand and supply strengthening strategy drawing on social and commercial marketing,
and behaviour change communication (BCC) approaches.
This case study uses the more comprehensive definition of sanitation marketing as an approach to
increase access to household sanitation at scale.
To understand how CLTS and sanitation marketing are integrated in Cambodia, it is useful to look more
closely at three different ways that CLTS and sanitation marketing could potentially occur:
1. Traditional CLTS
2. Sanitation Marketing
3. Hybrid CLTS-Sanitation Marketing
1. Traditional CLTS
The traditional CLTS approach is mostly carried out by Provincial Department of Rural Development
(PDRD) with support from NGOs.
The approach follows four phases of engagement at the village level:
1) Pre-triggering in the first month, meetings are held between implementers and local people to
prepare a work plan, Participatory Village Assessments (PVA) to collect baseline data on households
and sanitation are conducted, village chiefs are oriented to CLTS, and consultation occurs with the
community.

2) Triggering during triggering adults and children are triggered using standard CLTS tools. This is
followed by the preparation of a community sanitation plan, identification of village volunteers to be
behaviour change champions, and the election of a village focal point to work with PDRD until ODF is
reached. At this point some households stop open defecation and use a latrine either by sharing with
relatives, or building their own.
3) Post-triggering this phase involves an initial follow-up visit by PDRD or an NGO one week after
triggering, then monthly follow up visits. After three months, behaviour change and hygiene triggering
occurs. Regular monitoring visits may continue until ODF is reached, which could be from six to 12
months after triggering.
4) Post ODF when a village achieves ODF status, monthly follow-up monitoring is planned, however, in
practice this usually falls to the community itself.
The opportunities for integration of sanitation marketing in the traditional CLTS model could occur in the
first three months of the process: at pre-triggering, triggering and post-triggering phases. In practice
there is no uniform approach, with NGOs and PDRD introducing sanitation marketing at various times or
not at all.
Sanitation marketing is introduced in different ways. Some NGOs invite sanitation suppliers to promote
their products at the initial triggering session. However, a communitys exposure to CLTS triggering (and
thus sanitation marketing) may be quite narrow depending on who attends the triggering session. With
PDRDs limited resources, villages are only triggered once, which means that in larger villages as few
as 25 per cent of households may be directly exposed to both demand triggering and sanitation supply
information. The assumption is that exposed households will tell others about the need for sanitation and
the available products, but this is not guaranteed.
Other NGOs invite sales agents from sanitation businesses to talk to groups of households during the
BCC sessions, up to three months into the post-triggering phase.
Some CLTS implementers do not engage with sales agents or sanitation suppliers at all.
It would be wrong to think that villages selected for CLTS have had zero exposure to sanitation
marketing. Sanitation marketing has been formally introduced in 15 out of the 25 provinces in Cambodia,
but even outside of these provinces, some sanitation products and materials informally find their way to
communes and villages.
It is therefore possible to make links between CLTS triggered villages and some type of sanitation supply,
but under the traditional CLTS approach integration with sanitation marketing is ad hoc and unstructured.
CLTS implementers, especially provincial governments, tend to treat sanitation marketing as the private
sectors responsibility, and expect that the market will take care of itself. Traditional CLTS implementers
often do not consciously make links with sanitation marketing. For example, the previous exposure of a
village to sanitation marketing before CLTS triggering is not usually part of the information collected in
participatory village assessments and other baseline data, but it could be.
Opportunities to link with sanitation suppliers in the district or province are missed because no one is
thinking about this. A UNICEF officer recalls a field visit with PDRD:
In theory we all support collaboration with NGOs and PDRD and RHC to discuss who is doing
what, but in practice no one is thinking broadly. For example, when travelling to a village for CLTS
implementation in some provinces there is a big latrine producer along the road to the community
but PDRD does not stop the car and talk to the producer to ask questions such as where do you
sell it, how do you sell it.
Research by WaterSHED in CLTS and non-CLTS villages shows that initially sanitation coverage might be
higher under CLTS, but people were building pit latrines because someone told them to. Pit latrine use
was not sustained. The study findings were that CLTS helps to prime demand, but to achieve sustained
norms, the product matters. Consistent usage is linked to product satisfaction people are more likely to
use and maintain their preferred toilet type.

2. Sanitation marketing
Two NGOs, WaterSHED and iDE, have been involved in developing a scalable, replicable sanitation
marketing approach in Cambodia since 2009. The initial development phase included market research and
analysis to understand rural demand, consumer preferences and barriers, sanitation coverage, available
technology, the rural supply chain, and national level barriers. After piloting sanitation marketing and
product testing low cost sanitation models for 18 months, both NGOs have scaled up into 15 provinces.
The near universal consumer preference for pour-flush latrines led to the development of an entry level
pour-flush easy latrine retailing for US$ 30-35.
Starting sanitation marketing in a new area involves going door to door and holding meetings to introduce
the concept to suppliers, local authorities, village officials, commune councillors, and provincial officials.
iDE and WaterSHED deliberately bring businesses, village chiefs and local authorities together and work
hard to establish relationships and trust between them.
Once the relationship is established, work begins

on giving practical support to latrine businesses. It Challenges for sanitation businesses
is these businesses that are the key to unlocking Sanitation is only one part of the
the rural sanitation supply, thus developing their business
skills is critical. Businesses are supported to
develop a business plan, and coached and trained Latrine sales are seasonal, with few
in sanitation marketing aspects. Finally, attention is sales in the wet season
given to improving the product supply chain, based Labour is not stable skilled staff leave
on up-to-date research about what consumers and go on to other jobs
want.
Production costs are high at 65-75 per
Having available products is just one of the many cent of the sale price of latrines
elements in sanitation marketing, and it is not the No skills in managing sales agents
most important. According to Lyn Mclennan from
WaterSHED, Marketing is key how to market Passive, lack confidence, skills and need
to rural consumers who have not thought about ongoing training
having a latrine before?.
One way to market is through village level sales events. These events are village gatherings that would
typically involve displays, demonstrations and the promotion of latrine product options. In Cambodia,
however, most of the time and attention in these sales events is given to sanitation demand creation
rather than product promotion.
For Cambodia our case is particular because there is no wide scale behaviour change/demand creation
activity such as a Government programme. Our sales events are 90 per cent explaining why the product
is important, 10 per cent about product information. Lyn Mclennan, WaterSHED.
Many elements of sanitation marketing or behaviour change in these sales events draw directly from
CLTS tools and triggers. For example, the F-Diagram, hair in the water, faeces calculation, and the cost of
latrines versus medical expenses are used effectively. This CLTS inspired approach does not just focus
on disgust but is tailored for the sales context and includes status, pride, privacy, convenience, and cost
saving benefits as motivating factors. The difference with CLTS is that the tools are used to motivate
individual household latrine ownership and drive sales of low cost latrine packages, rather than stop open
defecation.
These CLTS-inspired promotional events are facilitated by sales agents. In the case of iDE the sales
agent is a full-time staff member of the NGO. A more hands off approach is taken by WaterSHED,
whereby the NGOs field staff facilitate and support sales agents, often community leaders
commissioned by sanitation enterprises, to generate sales. Field staff also support latrine suppliers in
their effort to create demand, and manage orders, payment, and delivery.
Sanitation marketing activities are occurring across 67 per cent of districts in Cambodia so it is inevitable
that NGOs supporting sanitation marketing encounter CLTS implementation and subsidy approaches.
WaterSHED develops agreements with all NGOs working on CLTS in the same geographical areas to try
and improve the programming of sanitation marketing and CLTS. However, according to WaterSHEDs
experience, while it is possible to build synergy with CLTS efforts (more so than subsidy approaches)

agreements with NGOs have not always translated well into cooperation on the ground, and integration
has not been smooth.
A random study of 36 villages in Kampong Speu province where WaterSHED implemented sanitation
marketing found that sanitation coverage increased from 24.8 to 41.3 per cent between 2009 and
2012. Of the sample villages, 12 had been exposed to CLTS prior to the marketing intervention, and an
additional nine were exposed to CLTS triggering over the project period. The results suggest that there
is very little difference in percentage point increases in sanitation coverage between non-CLTS villages
(16.1 per cent) and CLTS villages (16.9 per cent). CLTS is not a prerequisite for the early uptake of latrines
through a market-based approach, but it may play a role in achieving 100 per cent access. The study
further concluded that CLTS does appear to be associated with higher increases in villages with low and
medium sanitation coverage at baseline. Sales agents or sales-commissioned village chiefs, who reside
in the village appear to be more important drivers of change. Two factors that need to be considered from
this data to understand the effectiveness of integration are: what was the quality CLTS facilitation and
triggering? If this was poor then it may have affected sanitation demand, and to what extent was there
real integration of the two approaches? Could the results have been better if there was close coordination
and integration between NGOs implementing CLTS and sanitation marketers?
A difference from CLTS is that sanitation marketing practitioners talk about coverage rather than achieving
ODF. This is because their focus is on hardware, and certain behaviours for achieving 100 per cent ODF,
such as the disposal of infant faeces, are difficult to monitor. That does not stop WaterSHED working
with PDRD to help them achieve their target of 100 per cent ODF communities. Despite this difference
in measurement, WaterSHED has seen communities shift from 20 per cent coverage to high or 100 per
cent sanitation coverage. A study by WSP found that sanitation marketing has contributed significantly to
the sanitation increase in Cambodia over the past few years with nearly 270,000 latrines sold between
2009 and 2015 from partners alone. The latrines sold account for more than 55 per cent of number of
pour-flush latrines during 2008-2013.
There are still significant challenges for sanitation businesses in Cambodia.
Khmer business is passive. Most people sit in the hammock and wait for the business to come. To get
them up out of that hammock is difficult they say my business is going okay, Ive got food on the table,
my kids are going to school. This is different to other countries where businessmen and women are
tough. Lyn Mclennan, WaterSHED.
CLTS practitioners are in a perfect position to be saying this village is getting it, we need to make
sure there is a supplier and sales agent getting in to communities to meet the demand that has been
generated.
3. Hybrid CLTS and sanitation marketing
A hybrid model of first building the sanitation market, then creating demand for sanitation is implemented
by SNV, World Vision and Plan International. This approach has its roots in the WSP Sanitation Demand
and Supply in Cambodia Study which found that people prefer good quality pour-flush toilets. A market
usually provides these latrines, rather than households themselves, so if the market does not exist then
this is an obvious bottleneck for households to get the toilets they want.
Underpinning this approach is the need for a handshake between suppliers and consumers at the
optimum time so that when households have the desire and have decided to buy a toilet, there is a
sanitation market ready to supply the toilet; and conversely once sanitation suppliers are ready to supply
products they are brought to the community to connect with people who are generating the demand.
This approach aims to create not just ODF communities but quality, sustainable sanitation.
For SNV, a district-wide approach to sanitation, rather than focusing on individual communities, is the
key to effectively bringing sanitation marketing and CLTS together. Through its Suitable Sanitation and
Hygiene for All (SSH4A) programme, SNV supports the capacity development of local government so
they can lead and accelerate progress towards improved sanitation coverage. The SSH4A combines
sanitation demand creation, sanitation supply chain strengthening, hygiene BCC, and WASH governance.
Before any work begins on sanitation marketing, SNV starts by supporting district and commune
governments to assess the sanitation situation and open defecation rates in their areas. SNV helps

local governments understand the sanitation problem and address this as a total sanitation package.
Governments develop their own sanitation and hygiene plan, make commitments to achieve 100 per cent
ODF and set deadlines for becoming ODF. SNV facilitates the Government in answering the question of
how to reach this target, and what are the different approaches needed to get there. CLTS can be one
component of this package, but fixing up the supply chain gets attention first.
When assessing the supply chain in new villages and communes, SNV looks at:
1. if there is any partner doing sanitation marketing;

2. if there is any existing supply chain which is offering services and products; and
3. if it is necessary to build up a new sanitation market.
This sets the direction for how sanitation marketing will move forward within the local context. Supply
chain development strategies for sanitation and hygiene aim to ensure that an increased range of options
and services are available, products are less expensive and more responsive to what consumers want;
the buying process is simplified; outreach is improved; information and marketing is available; and the
right people and local enterprises are engaged with the potential to put into practice sustainable business
models for reaching the target consumers.
How does CLTS fit in? CLTS is a key tool in triggering sanitation demand, but in this case CLTS is directly
linked to the supply chain which was previously developed. Deliberate efforts are made to connect with
sanitation marketing partners such as iDE or sanitation businesses in the area, who can introduce sales
agents to the village to sell products after triggering. Sanitation marketing and CLTS are integrated and
coordinated as part of a total sanitation package at the district level.
There is no benchmark for how long it takes a community to get to ODF but it can range from 6-12
months. The results speak for themselves. In 2012 the district of Banteay Meas had one of the lowest
levels of sanitation coverage in Cambodia with only 16 per cent of household having access to
sanitation. By late 2014 over 80 per cent of households had access to, and used, toilets, with seven
communes declaring ODF and 46,000 people living in ODF communes. The district has set a goal to be
100 per cent ODF in 2015 with eight more communes to be declared ODF.
Although the timeframe for reaching ODF status is the same as the traditional CLTS approach, the affected
area for the hybrid approach is commune-wide rather than individual villages, and post ODF follow-up is
strong. Support to the commune continues with post ODF follow-up to develop a plan to sustain ODF over
time and address and strengthen key behaviours that are lagging such as handwashing.
The commitment of the government and leadership are the crucial thing in creating ODF all the other
activities are supporting, but without these two, even if you had great CLTS implementation and a supply
chain it is much more difficult to get the result. Petra Rautavuoma, SNV.
When the SSH4A began, over 90 per cent of ID Poor Households in the programme target district
practiced open defecation and in several communes none of the poor households had access to
sanitation. As SSH4A sanitation increased dramatically over the 18 months, access for poor households
remained slow. To improve this some sanitation businesses in Banteay Meas district offered customers
one to three months interest free credit which works well and allows many poor households to build
toilets. SNV has also introduced a pro-poor sanitation fund which supports the poorest households (ID
Poor 1 and 2) to access sanitation vouchers so they can then purchase sanitary toilets through suppliers at
a discounted price. Each ID Poor Household has to sign an agreement with the village chief committing to
construct the toilet within an agreed timeframe, as well as to use, clean and maintain the toilet.
When the SSH4A programme started only 2 per cent of the ID Poor Households in seven communes
had an improved sanitary toilet. By the end of November 2014, 734 ID Poor Households had received the
sanitation voucher (which is 3.5 per cent of the households in Banteay Meas district.) 65 per cent of the
ID Poor Households in the seven communes now are using an improved sanitary toilet.

Lessons learned
What has been learned about the integration of sanitation marketing and CLTS in Cambodia?
For one, integration of CLTS and sanitation marketing is still limited in Cambodia which makes calculating
the impact difficult. The different methods of integration range from informal integration of sanitation
marketing into CLTS triggerings; using CLTS type tools during sanitation marketing; and a comprehensive
planned integration.
The main conclusions are that:
There is merit in trying to integrate the approaches in some way as CLTS provides the demand
creation, and sanitation marketing the product and supply chain needed to deliver sanitation at scale.
The deliberate integration to connect the two parts of sanitation marketing and CLTS is more effective
for achieving 100 per cent ODF status and sustainable sanitation. Leaving integration to happen
through natural market processes produces weak results.
Integration requires coordination and communication between those involved in CLTS and sanitation
marketing to optimize the timing of both approaches, particularly the readiness of the community to
purchase toilets and the readiness of the market to meet demand.
Programmes that integrate demand creation, supply strengthening and institutional support will
require more resources and have higher costs than those that implement CLTS only or sanitation
marketing only.22
Other factors are important to the success of an integrated approach e.g. quality of CLTS facilitation,
engagement of local leaders and institutional arrangements.
CLTS and supply chain development are not one-time activities but ongoing processes which need to
be led by local government.
Sanitation marketing is an essential part of the sanitation equation for Cambodia. All sanitation
practitioners seem to agree that when people get what they want (i.e pour-flush toilets) these toilets
are more likely to be sustained than short term dry pit latrines. But this requires a market to supply the
materials, products and services.
What next for Cambodia?

The opportunities to closely link CLTS with sanitation marketing are just being uncovered in Cambodia.
Future steps that would help this integration are:
Mapping of where sanitation marketing is occurring and where CLTS is being implemented.
Gathering more evidence on sustainability of CLTS and sanitation marketing integration.
Local government takes the front foot for collaborating at sales events and triggering events, with less
hand holding by NGOs.
Annual technical and progress reviews between practitioners on the links between sanitation
marketing and CLTS.
Cambodia is thinking about an association of sanitation providers (similar to water associations in other
countries) which could provide industry capacity building and collaboration to help sustain sanitation
businesses.
Even at the highest levels Cambodia seems open to that idea and improving the integration of CLTS and
sanitation marketing.
I still think that it is not CLTS alone that is the solution it has to be more integrated, a more holistic
way of thinking to make it happen if you want to reach 100 per cent ODF Chreay Pom, Deputy
Director, Ministry of Rural Development.
22 WaterSHED estimates promotional costs of US$18-20 per toilet installed.

References:
WaterSHED (2012), Characteristics of Household Sanitation Use and Demand in CLTS and non-CLTS
Villages: A comparative study from rural Cambodia.
WSP (2012), Sanitation Marketing Lessons from Cambodia: A Market-Based Approach to Delivering
Sanitation.
WSP (2008), Sanitation Demand and Supply in Cambodia.
SNV (2015), Counting down to the first ODF district.
http://www.snvworld.org/en/regions/asia/news/counting-down-to-cambodias-first-odf-district#
SNV (2015), Sustainable Sanitation and Hygiene for All,
http://www.snvworld.org/en/cambodia/our-work/WASH/SSH4A
WSP (2011), Introductory Guide to Sanitation Marketing.
WaterAid (2015), How to sell toilets: a new approach to sanitation marketing in South East Asia.
http://www.wateraid.org/news/news/how-to-sell-toilets

INDONESIA

Indonesia: CLTS in Indonesias decentralized context: At what
level is support most effective for scaling up sanitation?
Many countries are going through some type of decentralization process, with responsibility for
development issues, including sanitation, devolved to subnational governments. The challenge for
development agencies is understanding how best to deploy limited resources to effectively increase
access to sanitation and ensure it is sustained.
For Indonesia, the challenge is how to leverage money and resources at the right administrative level to
scale up sanitation through CLTS to meet the countrys ambitious sanitation targets. Recent experience
from Government, UNICEF, Plan International and the World Banks PAMSIMAS programme and
the Water and Sanitation Program (WSP) provides some lessons on where and how to add value to
decentralized Government structures to expand ODF status and sanitation access.
Background
CLTS is a Government programme in Indonesia

Rural sanitation in Indonesia has seen some remarkable progress in recent years. Following the
introduction and success of the Community-Led Total Sanitation (CLTS) approach in 2005, the
Government, under the leadership of the Ministry of Health, has developed the Community-based Total
Sanitation and Hygiene Strategy (STBM), which takes the CLTS approach and complements it with hand
washing with soap, hygiene, safe food and water treatment, safe wastewater management, and solid
waste management at household level. At the same time, the Government is actively encouraging the
private sector to deliver affordable sanitation products and services, with local sanitarians and health
cadres taking a key role in behaviour change and demand creation. Since rolling out in 2008, STBM is
now accepted as the standard approach for sanitation across Indonesia.
Sanitation remains a huge challenge

Despite decreasing open defecation from 40 per cent of the population in 1990 to 20 per cent in 2015
the remaining challenge is enormous simply because of the number of people in Indonesia. The 2015
JMP estimates of household access to sanitation, compiled by UNICEF and WHO, show that only 61 per
cent of the 255 million population has access to improved sanitation, with 51 million people practicing
open defecation, and a total of 100 million people having unimproved or no sanitation. Indonesia has the
second largest number of people open defecating in the world, after India. Household survey sources
such as the National Socio-Economic Survey (SUSENAS) and Basic Health Survey (RISKESDAS) clearly
show that nearly all open defecation is by the poorest 40 per cent of Indonesian people.
The Government has recently revised its National Development Target of universal access to sanitation to
be achieved by 2019. This is an ambitious target to achieve in a short time.
Who is responsible for achieving sanitation targets?

Following decentralization reforms in 2001, responsibility for sanitation services was handed from central
to local city and district level. Central Government, including the national line ministries responsible for
water and sanitation service provision, now focus on policy and strategy development, and oversight
of implementation rather than direct control of service delivery. The Ministry of Public Works is the lead
agency for providing water and sanitation infrastructure to urban and rural areas, while the Ministry of
Health is responsible for behaviour change and setting standards for drinking water quality. BAPPENAS
(Ministry of National Development Planning) is in charge of planning, setting sector targets and
policy development, while the Ministry of Home Affairs is responsible for capacity building for local
governments and their adherence to minimum service standards.
At the subnational level, districts and cities carry the authority to ensure service delivery, while provincial
governments provide oversight and technical support to their respective cities and districts. For the STBM
programme, local health offices and their sanitarian staff are responsible for carrying out the programme
in their communities, with support from local government, local and international NGOs, as well as
development partners.
To support the implementation of policies and strategies, and for the coordination of day-to-day activities,
technical working groups for water and sanitation (Pokja AMPL) have been established both at national as

well as subnational levels. The national Pokja is headed by BAPPENAS and comprises of representatives
of eight line ministries engaged in the sector, including the Ministries of Home Affairs, Health, Public
Works, Finance, Environment, Education and National Bureau of Statistics. The national Pokja is also
supported by various projects, NGOs, international agencies, donors, universities, etc. At the local level,
the Pokja are comprised of the respective local government agencies responsible for water supply and
sanitation. To date, Pokja have been established in all provinces, and in more than 500 district and city
governments, though these function with varying levels of intensity.
Challenges
Large scale, fragmentation and variability

Implementing a national government programme in a country consisting of more than 17,000 islands with
an ethnically diverse population of over 250 million the fourth highest population in the
world is very challenging. Administratively the country is divided into 34 provinces, over 500 cities and
districts, and more than 75,000 villages. There is a wide variation in the resources and capacity of each
province. Several provinces are isolated from central Government and receive little support and attention.
Conversely, under decentralization, provinces and districts operate autonomously and do not always
pay attention to central Government directives. The national STBM programme is fragmented across
Indonesia with many local departments involved in sanitation.
Weak coordination
When active and meeting regularly, Pokjas have proven to be a very effective forum to support and
coordinate sector development and stimulate change at the district level (e.g. Nusa Tenggara Timur and
East Java). However, the capacity to coordinate all WASH players and drive the STBM agenda depends on
the province, and this is not uniform across the country. At the district level very few Pokja are effective.
Lack of institutional capacity

After the decentralization reforms, the flow of Government money changed from central to provincial
level, to central to district level (effectively bypassing provinces), but with little support for service
delivery. A critical challenge for the sector is for subnational government to develop the capacity to
fulfil its devolved role in the planning, development and management of services; and for effective
instruments to be in place to hold it accountable for doing so.
The central government is currently planning to release around US$ 100,000 in development funds
annually to each village. In this arrangement the role of the district level is still unclear. Villages are
likely to have even less capacity than districts to plan services, manage these funds and monitor the
effectiveness of their use.
Lack of Government investment

The World Bank estimated that Indonesia needs to raise an estimated US$ 414 million per year in order
to meet its rural sanitation targets for 2019.23 About 43 per cent of these requirements are needed for
replacing facilities at the end of their economic life. Despite much of the required financing expected to
come from households (US$ 410 million), Government investment is still needed to create household
demand for sanitation and to leverage household spending to meet the 2019 target.
STBM is clearly the national vehicle for driving household demand to achieve these targets, yet very
little money and resources are allocated towards the programme. Indeed, STBM may be the victim of its
own advocacy as it has advocated for no subsidies; unfortunately this has been interpreted by some in
Government as meaning no money or resources are required without understanding that resources are
needed to run the programme, not build toilets.
In many districts, district mayors (bupati24) are not putting money into the STBM programme due to lack
of knowledge about the impacts of poor sanitation or the programme being a low priority.
Implementation strategy
23 World Bank Water and Sanitation Program, 2014, Water Supply and Sanitation in Indonesia Service Delivery Assessment.
24 Bupati are locally elected off.icials that run the district administration.

Targeting districts
Much of the past development partner and NGO support has been aimed at the district level. In UNICEFs
programme of support to three provinces (Nusa Tenggara Timur (NTT), South Sulawesi and Papua), staff
spend a lot of time advocating to selected district leaders to increase the priority and attention to STBM.
The reasons are clear: a bupati that understands and supports increasing sanitation has the power to
influence STBM implementation at subdistrict and village level by: issuing a regulation or decree to
implement STBM at lower levels; allocating funds specifically for STBM; and following up with district
administration that these funds are being used for the purpose and achieving results. These key actions
signal to subdistricts and villages that sanitation is important and that the bupati has expectations on
progress, and will pay attention to STBM being carried out.
An example of the effectiveness of the bupati is from Alor district in Nusa Tenggara Timor province.
Although the bupati took some time to be convinced of STBM, when he became interested he
implemented STBM in 15 villages that were subsequently declared ODF and then showcased these
achievements to the remaining village heads, with a clear message that they too should implement
STBM. Recently a further 30 villages have followed with ODF declarations.
The World Bank PAMSIMAS programme has also found that where districts are declared ODF there is a
correlation between this, the strength of bupati, and their interest in sanitation. If the bupati advocates
for ODF and it becomes one of the programmes for the office of bupati, the budget and the regulation
will be there and it will become the priority of the subdistrict and village government because of the
strong push from the head of the district.
What does it take to influence bupati and increase sanitation? UNICEF has found that in Nusa Tenggara
Timor, progress at district level is much better where there is a facilitator placed in the district to support
the STBM process, including facilitating and advocating for a STBM budget at the district level, but also
helping the sanitarian and health centre trigger and implement at village level. A district facilitator can
use a limited amount of development agency or NGO implementation money, to leverage district budget
and continue replication in other villages. Long term engagement is needed. Both Plan International and
UNICEF are funding facilitators at district level for up to three years.
Experience from Nusa Tenggara Timor shows that districts do well if: (i) they have a good facilitator and
process; (ii) if additional financial support is provided by an agency for leveraging purposes, (iii) local
leaders are involved then they can positively influence budget allocation by the district government. To
help institutionalize this successful approach, UNICEF, together with BAPPENAS, put together advocacy
kits for bupati, using facts and infographics to help them understand the issue of poor sanitation and
guide them in the steps they can take to change the situation, such as allocating budget towards STBM
implementation; taking time to talk with the district administration and calling in the head of the district
health office to ask about STBM progress; and issuing a decree.
By targeting district level implementation it is possible to achieve sanitation outcomes, but this approach
requires time, resources, and skills in advocacy and facilitation, and is difficult to scale up quickly. With
more than 500 districts and cities in Indonesia, getting to the required scale to reach universal sanitation
is beyond the capacity of NGOs and development agencies. Papua province is a good measure of the
STBM challenge: just nine out of 29 districts are implementing STBM (in just 25 out of 385 subdistricts)
and 174 out of 3,538 villages.
Provincial level influence

A question to consider in scaling up is: how can the experience from district support flow upwards to
the province level and then be used to spread implementation in other districts which have not been
supported by external agencies?
UNICEF has found that there is efficiency in supporting provinces as well as districts to increase scale.
Despite provinces having little direct responsibility for implementing sanitation, the provincial governor
is still a powerful influencer of what happens at district level and lower, and which development agenda
gets prioritization. For example in Nusa Tenggara Timor province, UNICEF has a full time coordinator
at the provincial level and facilitators at selected districts. The coordinator works with the provincial
Pokja to facilitate, develop skills, and guide planning processes to prioritize sanitation. If the provincial
governor is convinced about the need for better sanitation, and issues a regulation to implement the
STBM programme to achieve ODF villages, then this is a tool to communicate with local government to
allocate their budget and implement the programme. The Governors regulation in Nusa Tenggara Timor

was disseminated to all districts and they in turn created a similar regulation about STBM. This triggers
the district government to provide budget for STBM which is then followed by budget allocation from the
District Health Office and the health centre level. In Nusa Tenggara Timor, 20 out of 22 districts have a
local regulation from the bupati on STBM.25
Provincial level support has other benefits too. Improving coordination at the provincial level through the
pokja can also strengthen coordination at the district level. In a province such as Nusa Tenggara Timor,
where there are number of agencies including the PAMSIMAS programme, Plan International, UNICEF,
and others, the provincial pokja has a key role as a central point for capturing learning and sharing
information as well coordination of efforts. If the provincial pokja is meeting regularly and coordinating,
together with the governors regulation on STBM this gives impetus to district pokja to meet and
coordinate, and share information.
Another finding from Nusa Tenggara Timor is the influence of the provincial level in the planning cycle and
getting financial commitment for STBM from districts. Those districts that have funding earmarked for
STBM in their 2013-2018 medium term development plan can allocate budget for implementation, but
without identified funding it is difficult to later allocate budget. The provincial pokja encourages districts to
include budget in their multi-year plans for STBM, and for the remainder, the provincial pokja continues to
advocate for those districts to review their development plan to include STBM and then allocate budget
for it.
Provincial level influences can also be seen in Papua province where the local government receives
special autonomy funds from the central Government in addition to its regular budget. The provincial
governor has directed that 80 per cent of the special funds go to districts while 20 per cent is retained at
provincial level. UNICEFs full time provincial coordinator was able to advocate that some of this special
funding be allocated for sanitation activities, especially STBM. The outcome was a Governor decree,
giving direction that a portion of the health funds allocated from the special autonomy budget to districts
should be used for STBM implementation. The money is not enough for each district to automatically
allocate funds for STBM so districts are encouraged to co-contribute.
The provincial government is also crucial in monitoring how budget is spent and the progress of activities.
In Papua the province monitors district spending through annual provincial meetings. In this way, the
province checks whether districts have allocated funds for STBM, and advises them to if they have not.
The province particularly targets those districts that have been exposed to STBM awareness, but have
not yet allocated any funds for it.
The province can also provide important technical support on STBM for districts. An example is
Papua province, where all district health offices meet at the provincial level to review progress and
achievements through an annual STBM network meeting. The province also allocates province health
funds for the training of district staff as a way of spreading capacity. In 2013 the provincial health office
trained representatives from nine districts not implementing STBM in Papua, and conducted training in a
further two districts in 2014.
The World Bank Water and Sanitation Program now works with provinces to lead and implement the
programme through districts.26 Provincial level technical assistance includes: capacity building of local
government at provincial level and some at district level (using the provincial budget); and supporting
provinces to make strategic plans for effective STBM implementation at the district level. According to
WSP, persistence is needed for the long process of developing a relationship, mentoring, advocacy, and
providing data and information to aid decision making for provincial government staff, especially the
health office. Giving all the data, updating information, giving them fact sheets, makes the province
really trust us to help them.
Subdistrict supervision
Another approach to scaling up is through intensive follow up at the subdistrict level. In Papua province,
25 Except Kupang city, and Malata which is a new district without a bupati.
26 Originally in 2008 WSP supported STBM in 29 districts.

Jayapura district has piloted an approach which builds the capacity of subdistrict staff and helps them
implement in all 5-10 villages within each subdistrict. This involves a meeting at the subdistrict level with
the sanitarian from the health centre and other members of subdistrict office staff to introduce the STBM
concept and establish if there is interest to start implementation in a village.
Subdistrict staff and trained volunteers conduct triggering, with the subdistrict team continuing to follow
up progress for four to six months after triggering. At this very localized level follow-up can be regular. In
some villages sanitarians are following up daily, in others, weekly. The follow-up is not always guaranteed.
In Biak a special facilitator is employed by a local NGO to follow up on a daily basis. The success of ODF
is directly linked to intense follow-up.
UNICEFs involvement extends to the subdistrict level through the discussion of triggering results and
a follow-up meeting (at subdistrict level) after three months to discuss the progress of each village.
This strategy will be replicated by local government taking the place of UNICEF. The district has already
contributed money for implementation, and in 2016 the budget will be increased further as new areas
expand and district monitoring increases.
Sanitarians and village priorities

With new development funding being channeled directly to villages all over the country, and for places
like Papuas where there is already special village funding, effective use of this money at the village level
becomes critical while at the same time the capacity constraints are amplified. From Papua experience,
the sanitarian is a key person to influence village priority for sanitation and the allocation of resources and
funding for this purpose. In Papua only some villages have allocated funds for sanitation. This is because
the sanitarians responsible for these villages have been trained in STBM methods. The five-day STBM
training course for sanitarians includes a module on advocacy skills and how to influence village heads
and subdistrict staff to use funds for STBM. There is a clear link with trained sanitarians and their ability
to advocate and persuade the village head that sanitation is an important issue. The money that becomes
available is usually directed to building public toilets, or targeting support for the poorest families, or
improving temporary dry pit latrines to more sustainable pour-flush types to meet STBM standards.
Full STBM
In Indonesia a lot of focus in the STBM approach is only on sanitation, with little attention to all five pillars
of STBM. Plan Internationals experience shows that the model of multi-level support (provinces and
districts) is effective when implementing the full STBM, including: ODF, handwashing with soap, solid
waste, clean water, and wastewater disposal. In 2011 Plan implemented STBM in Grobogan district in
10 subdistricts, totalling approximately 153 villages. After two years all 153 villages were declared fully
STBM and within four years the entire Grogoban district achieved full STBM on all five pillars. This was
achieved through the placement of a Plan facilitator at the subdistrict level.
More recently, with a grant from Australias DFAT, Plan International is supporting five districts in
Nusa Tenggara Timur to become fully STBM. The approach has been adjusted to target district level
implementation with support from the provincial level, and to deliberately leverage Government planning
and financial support. Plan International has a project manager at the provincial level to work with
local government and manage its five district facilitators. Importantly, Plan provides capacity building
for Government and implementers in districts to do triggering. The facilitator in each district works to
strengthen the pokja, especially for implementing a rolling plan, which sees Plan support decrease while
district funding and involvement increases exponentially. In the first two pilot years, 150 villages were
targeted but this expanded by a further 300 in the subsequent two years when Government took over.
Plan funds the provincial project manager and district facilitators, and assists with monitoring, but the
Government pays for and leads the implementation, whilst gaining the capacity to expand at scale.
Lessons learned
District interventions are difficult to scale quickly Development partners and NGOs have limited
resources and cannot work in over 500 districts and cities, and even the largest NGOs are only
working in a handful of districts. There is not enough capacity and resources to directly support all 34
provinces, so the leveraging of local government funds is critical.
More than money is needed To scale up STBM and achieve ODF it is not just money that is
needed, equally important are: prioritization, regulation, and leadership on sanitation from all levels

and then to channel this around solid programming principles that have a strong evidence base (such
as use of formative studies) and which are regularly monitored and reviewed.
External agencies should support both province and district It is not a case of external agencies
supporting either/or provinces or districts, with experience showing that support is needed at both
levels, and possibly at subdistrict level.
Diverse capacity building required External agency support is not simply required for
implementing sanitation, but for building essential skills in advocacy for decision making, improved
planning, coordination, budgeting and monitoring.
A long-term engagement is essential UNICEF, Plan and WSP are funding people in specific
provinces and districts for a minimum of three years. This long term engagement is needed to build
trust and effectively work with local governments.
Sanitarians are a critical link Sanitarians are the key to implementing STBM but there is a large
deficit in people to do the work, the quality of sanitarians varies and not all of them have been
properly trained. Sanitarians also need to be closely supervised to ensure reporting and follow up, so
a higher level of support for implementation is very important to have in place.
Changing staff in local governments It is common for there to be frequent staff turnovers or
position changes at the local government level. For development partners this means having to restart
training and capacity building processes again. While unavoidable, the situation can be helped through
a long-term engagement.
Start small with quality then scale Rather than trying to implement STBM in entire districts
or provinces it is better to start small in a limited area, and embed processes with Government
commitment to expansion built in. In Indonesia the government mandate is to provide services for
all, and sometimes this results in a tendency for the Government to spread resources too thinly to
provide something for everyone rather than doing something well in one area and then growing
from this.
Communities have a crucial role Experience from Aceh shows that villages that easily became
ODF: did not expect outside assistance; had village leaders that were concerned and cooperative, and
made it easy to contact them and midwives; could easily gather the community together; had the
social capital of working together for a common good; and looked up to and followed the local leaders/
agents of change, i.e. religious leader.
Ingredients for a successful provincial level STBM enabling environment
What needs to happen
To facilitate
an enabling
environment
one should
have:
An effective
A solid evidence- approach to key
based advocacy target audiences
strategy according to local
Good relationship context
between the STBM
programme
influencer and key
decision makers

Monitoring strategies for scaling up STBM. The Ministry of Healths roadmap for sanitation is
being finalized and Bappensas has a programme (PPSP) to help local governments plan for sanitation
acceleration. One critical gap is the role of the Ministry of Health to oversee progress on scaling up, and
how to push poor performing provinces so that every district and every province is brought up to the
same level. Responsibilities for funding, supervision and monitoring between the central level Ministry of
Health and provincial/district and subdistrict health need to be better defined and streamlined as part of
this scalable model.
Increase in advocacy to drive prioritization of sanitation and ODF. Provincial sanitation targets focus
on health and education, or on sanitation coverage but not specifically on the achievement of ODF. In
Papua, for example, more could be achieved if the provincial governor is made aware of the connection
between the one million people openly defecating in Papua as one of the main contributors to the high
infant mortality rates and the poor nutritional status. At the central level, advocacy could increase political
will. Indonesia is the second worst country after India in terms of access to sanitation, but it does not
receive the national media attention and campaigns that India receives. Hence, UNICEF developed an
online advocacy campaign to raise awareness within Indonesia on the serious sanitation challenges the
country faces (see www.tinjutinja.com).
Targeting of the poorest and most vulnerable households. Concentrating on trying to get large
populations to ODF status creates a tendency to sideline equity issues such as vulnerable people,
women, people with disabilities, the elderly, children who may face accessibility issues and sources
of financing for affordable sanitation. In Indonesia there is no formal support mechanism for
low-income households on sanitation. There is potential to develop this through various means such
as Government targeting, innovative financing, religious organization support and Corporate Social
Responsibility.
Better knowledge of what it takes to scale up. Donors and NGOs need to have the costs and details
of what it takes to scale up STBM as part of advocacy to bupati. In most cases information on costs,
resources, and timing is not available, but this is exactly what district leaders want to know before
committing their own staff and budget.

Indonesia: Adapting CLTS for a major urban WASH
programme in Indonesia
Background
In 54 cities and districts within regions of North Sumatra, West Java-Banten-DKI Jakarta, Central Java,
East Java and South Sulawesi-East Indonesia, CLTS is being used to trigger behaviour change as part
of a comprehensive approach to improving urban sanitation. The Indonesia Urban Water, Sanitation and
Hygiene (IUWASH) programme aims to not only stop open defecation but also improve on-site sanitation
through a comprehensive approach to wastewater management. The IUWASH programme shows how
CLTS triggering can be adapted for urban settings but also highlights some of the complex challenges for
CLTS and sanitation in large cities.
Urban sanitation in Indonesia
Over half of Indonesias 250 million people live in urban areas. In the absence of public investments,
households have provided most of the sanitation infrastructure in place. The most recent 2015 JMP
figures put Indonesias urban improved sanitation (typically pour-flush toilets) at 72 per cent with 13 per
cent open defecation. While open defecation is still significant, existing toilets are the main sanitation
problem. With weak local government oversight and regulation, very few household toilets are built to
standard and do not dispose of wastewater safely. Many toilets discharge into a cubluk, an unsealed
tank or soak pit, also referred to locally as a tangki septik, or toilets discharge waste directly to drains and
waterways without any treatment. The health and environmental impacts of this situation are equivalent
to direct open defection.
The number of poorly operating household toilets is not known, but it is believed to be a huge number
across Indonesias urban areas. This number is not captured in official statistics because it is commonly
thought that having a toilet solves the sanitation problem. In some cities, traditional open defecation such
as public defecation over drains may be rare, but indirect open defecation is a hidden and very significant
problem.
One example is the city of Tangerang in Banten province. With 3 million people and a very high coverage
of household toilets, there would appear to be no open defecation problem. But a closer look at what
happens to wastewater beyond the household toilet shows that most toilets are connected to four inch
pipes at the back of the house which directly discharge waste into gutters, drains and canals. The effect is
the same as open defecation as faecal waste is not being collected and safely treated.
The challenge is getting the community and local governments to see that wastewater management is
a problem and needs to be prioritized. As a way to overcome this challenge, the IUWASH programme
is using CLTS tools to trigger demand for both improved on-site sanitation and demand for better city
sanitation management.
IUWASH approach
IUWASH is a five year (2011-2016) water supply and sanitation development programme funded by the
US Agency for International Development (USAID). IUWASHs sanitation component aims to create
access to improved sanitation facilities and services for 250,000 people (50,000 families).
IUWASHs approach recognizes the complexity of urban sanitation and the need for an interaction
between demand creation, sanitation options (supply), and city management of sanitation services to
achieve effective and sustainable sanitation.
To support sanitation sector sustainability IUWASH implements a series of structured activities:

promotion of behaviour change communication (BCC) for triggering community demand, support for the
development of enabling regulations at the local government level, identification of sources of finance
for the improvement of household sanitation, and institutional strengthening through the establishment
and capacity building of city Sanitation Management Units. These activities fit together in an urban
wastewater framework (Figure 1).

Figure 1: Urban sanitation coverage in Indonesia
10% Improved
Shared
72% 5%
Other unimproved
13%
Open defecation
Source: JMP Update 2015.
Figure 2: IUWASH Urban Wastewater Management Framework

Advocacy, legislation, enforcement, financing and strategies
Advocacy, legislation, enforcement, financing and strategies

Triggering Behaviour Change
Capacity Development, Behavior Change Communication,
Sanitation Triggering, Sanitation Promotion and Marketing
Regulation and Enforcement
Regulation and Enforcement

SAN 1: SAN 2:
On-site Systems Communal System SAN 3:
Household toilets through Communal septic tank, Centralized
SME and Micro Credit public toilets (by CBO)
(off-site) Systems
Small scale, small bore,
and citywide sewerage,
SAN 4: treatment, disposal,
and reuse
Integrated Septage Management
Collection, treatment, disposal and reuse
City Sanitation Management Unit

Operator of urban sanitation system, customer relation, billing, O&M
Triggering behaviour change
The objective of demand triggering in conjunction with sanitation promotion and marketing is the
elimination of open defecation and other inappropriate sanitation practice by improving individual
sanitation facilities (usually septic tanks) or the opportunity for connecting to an off-site reticulation
system.
IUWASH is supporting community demand triggering through CLTS or as it is known in Indonesia,

Community-Based Total Sanitation programme or STBM approach. STBM is a national programme by
the Ministry of Health that addresses sanitation, health and hygiene in five programmatic pillars: open
defecation free (ODF) communities, hand washing with soap at critical moments, household water
treatment and safe storage of water and food, solid waste management and liquid waste management.
The programme advocates a subsidy-free approach to sanitation, and the sanitation objective of STBM
(Pillar 1) is to attain an open defecation free status at the community level.
The Ministry of Health and local Department of Health and community health cadre already have
responsibility for promoting clean and hygienic behaviour, and take on the role and responsibility for
triggering and sanitation and hygiene promotion, with IUWASH staff working closely with them to
support the process.

The community triggering process in IUWASH is based on the STBM programme and involves:
social mapping by the community to create a map of the neighbourhood, and identify specific groups
and their hygiene and sanitation practices;
transect walk discussion about conditions and how they feel, what they might do to improve them,
photograph, interview people along the way;
structured focus group discussions after social mapping and the transect walk to discuss the findings;
introduction of the F diagram to identify how disease is spread and ways to protect the community
from contamination;
community exchange visits usually to another community that is more advanced in the sanitation
improvement process to find out how the improvement was managed; and
other meetings to discussion the sanitation situation and options.
Urban CLTS triggering may involve a transect walk which seems abbreviated compared to a rural transect
walk to an open defecation site, but it is no less powerful. The 30 minute transect walk involves visiting
small alleys to see the poor sanitation situation behind houses and to see where toilet waste discharges.
Signs of open defecation may be rare but visitors will experience raw waste discharging from houses,
foul smelling and often stagnant black water in drains and canals, and sometimes rats. A small number
of people may take part in the transect walk, but triggering is still effective because the community is
facilitated to see and understand the sanitation issue. The presence of the head of the village (keluarahan)
usually results in a quick decision to do something about the poor sanitation situation. The village head
can be motivated to improve the situation out of pride in their community and concern that the name of
the village will be associated with poor sanitation.
The use of mobile phone technology is a modern feature of urban CLTS triggering. The community is
encouraged to take pictures with their mobile phones during the transect walk as a way to record the
baseline sanitation situation and to capture examples of good sanitation practice. The photos can be
used as a talking point for those who are not able to be at the front of the transect walk line to hear the
discussion, or even for use in meetings when the sanitation problems are discussed with those who
could not attend the transect walk.
Household visits
Because urban residents often have busy schedules or need to work at night and not have the
opportunity to participate in triggering, community level meetings or other activities, IUWASH conducts
follow-up household visits to promote sanitation. Small two to three person promotional teams visit
households and discuss willingness and ability to improve sanitation, including: concerns and barriers to
improvement; technical options; benefits of improved sanitation and hygiene; costs and contributions;
importance of everyone participating; economic benefits e.g. lower health costs, less time lost due to
sickness.
After demand creation
Triggering helps the community understand that open defecation is a bad practice, but on its own this is
not enough to successfully change behaviour. The next step is to empower a community to fund or use
other financing options to build proper toilets or improve their current ones. Access to finance is critical
for low-income households who are unable to afford the cost of a simple toilet (approximately Rp 1.2
million or US$ 120). IUWASH has been working with microfinance organizations to provide loans for low-
income families, as well as establishing revolving funds in combination with technical training on healthy
toilet construction for low-income households, and microcredit systems with trained masons. To ensure
microfinance and microcredit systems are robust and suitable for different markets, IUWASH provides
capacity building to different financial providers, from banks through to cooperatives and small sanitation
contractors.
The technical aspects of sanitation are an essential part of urban CLTS triggering in Indonesia. In fact the
location to be triggered will vary depending on the feasible technical solution. Unlike rural villages where
the whole village is triggered, in urban areas for communal or networked systems only those affected
might be triggered, but for household systems, triggering of the whole community is needed. Triggering

includes detailed discussions with communities about septic tank technology and operation. IUWASH
works with masons and sanitation entrepreneurs to improve toilet and septic tank construction that
adheres to the Ministry of Public Works sanitation standards.
Challenges and lessons learned
The following are some challenges and lessons learned on how and why the STBM approach needs to be
adapted for the urban context.
Densely populated urban areas limit technical choices. Urban areas are much more densely populated
than rural areas. As such, basic, non-septic latrines or pour-flush pit latrines are not appropriate. Not
only is there no space to rebuild pit latrines when they are full, but they are not effective at creating
a barrier to disease transmission because people live close by and there is potential for the pollution
of groundwater, which many households depend on for their basic water supply. In urban areas the
household sanitation ladder is less relevant but collective septage management becomes very important.
Sanitation entrepreneurs need to be brought into the triggering process to support the more complex
technical solutions in urban settings.
Community engagement needs to be flexible and fast. It is difficult to organize events and activities in
urban areas in which all community members can participate. Therefore, the times of meetings need to
be flexible, or multiple meetings are needed to align with particular schedules. For example, if husbands
(as key decision makers) are working away from home, then meetings need to be scheduled when they
are present. Because residents do not have much time, CLTS triggering processes need to be short and
simple learning exercises.
Facilitators need advanced technical knowledge and communication skills. A facilitator needs to
understand the sanitation situation and how sanitation facilities fit into a holistic sanitation system, e.g.
how households can empty their septic tanks when full, and how much this would cost. Facilitators
can expect to be asked these questions by the community, thus they need to be ready with answers.
Facilitators must have a broad knowledge of how and who to coordinate with (agencies/field/community
leaders); costs and how to access finance; construction; maintenance requirements and where to get
technical support; need for sludge removal and how to access this; and relevant regulations on sanitation.
This skill set is different to that required of rural CLTS facilitators.
Neighbourhood pride is an effective motivator. Using shame as a trigger in urban Indonesia is not
effective. A better approach is to build on neighbourhood pride and self-esteem, religious values, and
positive role models of others who are of a similar social standing in the community and have good
sanitation. Facilitators must speak in a delicate way so that people see the problem for themselves; using
shame can result in residents rejecting the facilitator as an untrustworthy outsider.
Community cohesion is weaker in urban areas. Members of rural communities are often more willing to
work together to achieve a common goal, while members of urban communities may not have the time
or willingness to work together. It is also generally more difficult to enforce community-level rules (such
as a ban on, or sanctions against, open defecation) in urban areas. Strong local leadership, follow-up
household visits and other community engagement helps improve cohesion.
Different financial challenges to household affordability. Although urban incomes may be higher than
rural ones, poor and low-income households often have very limited resources (such as land or basic
building materials) and find that investing in any improvement to their home or community is very hard
because of more urgent day-to-day obligations. Also, as non-septic latrines are not allowed in urban areas,
the investment cost by families in appropriate sanitation systems is much higher. Providing access to
microfinance is a critical element in changing behaviour.
Renters are reluctant to invest. Many urban households do not own their home. They are renters or
staying in their community on a temporary basis, and consequently are reluctant to invest in improving
someone elses property.
Environmental regulations need to be enforced. Because of their complexity and the increased
interaction among people, urban environments naturally require more formal regulations and a more strict
enforcement of those regulations. Indonesia requires that all human waste is collected, disposed of and
treated properly. Such regulations need to be respected and enforced.

References
A Guide to Urban Sanitation Promotion, (2015) IUWASH.
Towards Sustainable Urban Sanitation Volume 6, March 2014. IUWASH.
WHO and UNICEF Water Supply and Sanitation joint Monitoring Program (2015) 25 Years Progress on
Sanitation and Drinking Water.
World Bank WSP, (2011). Lessons in Urban Sanitation Development Indonesia Sanitation Sector
Development Program 2006-2010.

KIRIBATI

Kiribati: No golden solution ODF is easy but sustainability is
hard in Kiribatis challenging environment
The Central Pacific nation of Kiribati, comprises 33 low lying coral atolls stretching along the equator. With
lagoons and white-sand beaches, the countrys 103,000 people appear to live in paradise. But Kiribati has
one of the highest rates of infant mortality in the Pacific region, at 47 deaths per 1,000 live births.27 This
shocking statistic is mainly due to diarrhoeal disease, caused by inadequate access to clean water and
appropriate sanitation.
The majority of the population of Kiribati lives in the Gilbert Group of 16 atolls in the west of the country.
The Gilbert Group includes the so-called Outer Islands, and the capital, South Tarawa. Nearly half of
Kiribatis population lives in the urban capital of South Tarawa.
Due to poor sanitation many children die from preventable diseases

before their first birthday. For this reason there is always a special
celebration when a child turns one year old. (Photo: P Dutton)
Open defecation rates in Kiribati are some of the highest in the Pacific sub-region. According to the
UNICEF/WHO Joint Monitoring Programme data in 2015 just 40 per cent of the population of Kiribati
has access to improved sanitation, with 36 per cent defecating in the open.28 In rural areas and the outer
islands the rates are even higher open defecation is practiced by nearly half of the rural population (49
per cent) and by more than 70 per cent in some outer islands.29
CLTS was only introduced in Kiribati in 2013 by UNICEF and the Ministry of Public Works and Utilities
(MPWU) through the EU-funded KIRIWATSAN 1 Project, but in a short space of time it has rapidly
changed behaviour and reduced open defecation on Kiribatis Outer Islands.30 Early efforts at adopting
the approach were boosted by a visit from Kamal Kar in 2013, during which training and demonstration
triggerings were held in North Tarawa. Very quickly the 13 villages on this island became ODF and on
11 May 2013 North Tarawa was declared the first ODF island; not just in Kiribati but in the entire Pacific
region. Previously about 64 per cent of its 6,000 people used the beaches and mangroves for defecation.
The success of the CLTS approach in North Tarawa led the President to set the goal of an Open
Defecation-Free Kiribati by 2015.
Following the success in North Tarawa, the MPWU and UNICEF planned to roll out CLTS to all
139 villages throughout the 16 Outer Islands, and included in the KIRIWATSAN Phase 1 Project,
complemented with funding from the Government of Kiribati. One year later, over 70 communities on six
27 Ministry of Health, 2012, Health Service Delivery Profile Kiribati 2012.

28 UNICEF and WHO Water and Sanitation Joint Monitoring Program, 2015 Progress on Sanitation and Drinking Water 2015 update and MDG
assessment.
29 Outer islands profiles, KIRIWATSAN-1 Project, January 2013.
30 The Ministry of Public Works and Utilities is implementing the EU-KIRIWATSAN project with technical support from UNICEF and funding from the
European Union.

Outer Islands had declared themselves to be free of open defecation. By October 2014 the number had
increased to 90 villages on 10 outer islands with the involvement of a total of 30,054 people representing
84 per cent of the triggered population and 29 per cent of the total population of Kiribati.
Pit digging. (Photo: B Tiim)
The shift from open defecation to ODF communities, has driven a large household latrine building effort.
Pit latrines and pour-flush toilets with concrete slabs and pedestals are popular. Island councils even
subsidized the cost of a concrete slab for pour-flush toilets as encouragement for island residents to
improve sanitation and stop open defecation. Under the KIRIWATSAN Phase 1 Project, chainsaws were
purchased for each island so these can be used to sustainably cut down coconut trees to make platforms
and slabs. Molds are also available on islands and pedestals can be made locally, which is critical for
success and sustainability of remote Outer Islands that lack even the most basic supply chain.
Using sustainable local materials for slabs and pit lining. (Photos: B Tiim)
This speed and scale of achievement is impressive. Part of this is due to a high level of commitment from
the President of Kiribati and Cabinet, who promoted CLTS as the main approach for increasing sanitation
coverage in line with the National Sanitation Policy.31
The massive mobilization to Outer Islands to launch the ODF campaign was due to efforts of people on
the ground. UNICEFs WASH Community Development Officer Beia Tiim has organized and cultivated a
Core Technical Group of 73 people from the Ministry of Health, MPWU, Ministry of Environment, Ministry
of Internal Affairs, Womens Federation, and other organizations to lead the CLTS roll out. Beia trained
the core technical group, together with Kamal Kar, in CLTS facilitation skills. They are now community
31 Monitoring Report: Water and Sanitation in Kiribati Outer Islands Phase I, Delegation of the European Union for the Pacific, (December 2013).

champions who go to the Outer Islands and work with Island Councils on triggering and changing
sanitation and handwashing behaviours.32 The strength of this cross-sectoral facilitation team has been a
cornerstone of the successful triggerings on Outer Islands.
If open defecation is being eliminated and people are using toilets, then where is the problem?
Kiribati has unique challenging physical and social environments which significantly affect achievement
and sustainability of ODF status.
For one, open defecation in the ocean or on the beach is a deeply entrenched social norm on all Outer
Islands. In the village lifestyle, open defecation is not only socially acceptable but it is a social activity.
There are also the issues of distance and remoteness. The country is made up of 33 small islands and
coral atolls spread out across a distance greater than the width of India. Simply getting the Core Technical
Group to the Outer Islands is a major challenge due to their remoteness, infrequent boat and flight
schedules and the cost and time required to visit these islands. Continuous monitoring, follow-up and
verification are critical to sustaining behaviour change and ODF status, however this is not easy to do in
Kiribati. As a result, a key lesson learned has been that building capacity for CLTS facilitation and follow-
up on each Outer Island through the Island Council, Medical Assistant and staff, is critical to sustainability.
Figure 4: Map showing the location of Kiribati
The most serious challenge is posed by the relationship between sanitation and drinking water. The
usual logic in CLTS is that stopping open defecation helps protect drinking water sources, but in Kiribati
stopping open defection by building and using toilets can actually harm drinking water sources. Many
people living in coral atolls rely on shallow groundwater reserves, referred to as freshwater lenses, to
provide drinking water. These lenses are very fragile and with porous coral soils, pollutants from human
waste and other sources easily enter the groundwater lens, threatening public health.
Kiribatis environmental constraint turns conventional logic on improved and unimproved sanitation
options on its head, as improved facilities such as pour-flush and flush latrines harm peoples health as
much as unimproved options like pit latrines.
Figure 5: Model of a freshwater lens
32 Handwashing is integrated into CLTS triggerings through family training, handwashing demonstrations, and messaging. ODF criteria include the
presence of a handwashing station.

Source: http://www.epa.gov/climatechange/impacts-adaptation/islands.html
As the demand is created throughout Kiribati for households to build their own toilets, it becomes critical
to develop a supply chain that gives people safe sanitation options that will not contaminate their drinking
water. There are few sanitation options to protect these groundwater lenses, and suitable technical
options are not low cost. Neither of the current sanitation options pit latrines and pour-flush toilets
protect the ground water, even though they have stopped open defecation. Households prefer simple
pit latrines because they are cheap and can be built quickly, but these can do more harm to public health
than the original practice of open defecation if they contaminate a freshwater lens that people depend
on for drinking water. Flush toilets are inappropriate for Outer Islands since they require scarce water for
flushing and costly septic tanks are prone to leaking.
To raise awareness of the impacts of sanitation on water supply, the New Zealand-funded Kiribati
WASH In Schools Project is introducing WASH safety planning to be used with CLTS triggering
techniques. WASH Safety Planning, similar to water safety planning, is an approach that schools and
their communities can use to identify the risks to their health from WASH practices, and take steps
to reduce their risk. Participatory mapping during CLTS triggering can be an entry point for identifying
and discussing health risks not only from open defecation, but also from poorly built latrines, pigs, and
household waste. Through this risk mapping process, the community identifies the risks and threats to
water supply and is triggered to modify what it does, in particular where people defecate.
The KIRIWATSAN 1 Project provides guidance to island communities on latrine construction for
example where to build toilets to protect the ground water table, safe distances of latrines from wells,
and identification of coastal areas suitable for building toilets where there is much less risk of polluting
ground water. Once people understand the risks to groundwater they accept the loss of convenience in
having toilets away from where they live.
Through the CLTS process and WASH safety planning, people are realizing the importance of maintaining
water quality and protecting water supplies. Reinforcement from Island Councils is important, but is most
effective where there is Sanitarian Aid to advise communities on toilet locations and enforces Island
Council by-laws on sanitation; and where there is a very active mayor. Currently, most Island Councils do
not have Sanitarian Aid.
Raising awareness of the risks of pit latrines and pour-flush toilets has had an unintended consequence.
The people who built toilets in the early stages of CLTS in Kiribati have since learnt that they are
contributing to ground water pollution. Many stopped using their toilets and reverted to open defecation,
but they do this covertly by hiding in the bushes.
Although the extent is not yet measured, the wrong sanitation solution has caused slippage in ODF
achievements. In Kiribati there are few right choices for sanitation. According to Marc Overmars from
UNICEF, dry latrines are the only option but finding a technology that is affordable, and acceptable to
communities demands and preferences is problematic. There is an interest in composting toilets as a
solution, especially from the Ministry of Environment, Land and Agricultural Development which sees
that there could be ways of using sanitation technology to improve agriculture through composting.
Another extreme solution suggested by some is for sparsely-populated villages on Outer Islands to have

designated open defecation safe areas, but this is not being seriously considered just yet.
A search is on for the most suitable technology, yet everyone agrees that there is no perfect technology
and a balance needs to be found between cost, environmental protection and user preferences. Currently
there is a coalition of partners working on developing suitable sanitation options New Zealands Ministry
of Foreign Affairs and Trade (MFAT), Australias Department of Foreign Affairs and Trade (DFAT), Asian
Development Bank, NGOs, and research partners New Zealand Institute of Environmental Science and
Research are all looking at technical options which are acceptable, feasible, affordable, and use locally
available products.
The researchers want to avoid past mistakes. Trials of composting toilets in Kiribatis Kirimati Island 20
years ago were largely unacceptable to the community, as the approach was primarily a technology-driven
solution without considering community preferences or taboos around handling waste. Unless there
is in-depth community engagement and decision-making, together with WASH safety planning, the
communities cannot grasp why they have to use composting toilets.
The coordinator for KIRIWTSAN Phase 2, Pauline Komolong, is also looking to Kiribatis Pacific
neighbours in Tuvalu for inspiration. A composting toilet project there was successful at gaining public
acceptance and there could be lessons learned to help Kiribatis problem. Under KIRIWATSAN Phase 2,
implemented by the Secretariat of the Pacific Community, two demonstration toilets of the Tuvalu design
will be provided in each community. While the composting toilet designs used by KIRIWATSAN 2 are
environmentally acceptable, they are financially out of reach for households on Outer Islands.
Another approach is to change the behaviour of the younger generation first. Under the Kiribati WASH in
To solve Kiribatis sanitation dilemma, community

engagement is key (Photo: B Tiim)
Schools Project, UNICEF and its partners will trial composting toilets in schools on four Outer Islands in
2015. The premise is that children can easily adapt to new behaviours, and that schools are a catalyst for
change and a suitable place to trial new technologies. If the trial proved successful it can be rolled out to
other schools in the Outer Islands and increase exposure to new technology on a wide scale.
Solving the issue of water and sanitation in Kiribati is one of the most difficult issues in the world.
There are no golden solutions, only compromises according to Marc Overmars from UNICEF. There
may not be a golden solution but it is clear that a range of solutions need to be developed collectively
by Government, development partners, NGOs, researchers, Island Councils, and most importantly, the
communities themselves. A stepwise approach is needed, which includes a strong enabling environment
and partnerships, and cost-appropriate solutions in the context of WASH risk plans. CLTS will continue to
play a key role in community mobilization and behaviour change, but achieving sustainable and healthy
ODF communities in Kiribati is a continuing process.

MYANMAR

Myanmar: Myanmar Doing the ODF two-step
UNICEF and the Department of Public Health in Myanmar, are experimenting with increasing the
sustainability of ODF through a two-stage certification process. The idea is to have a warranty or
probationary period of 12 months, during which time an ODF village is supported and monitored to keep
its ODF status. However, the village also risks losing its hard won ODF status if it is not careful.
Myanmars ODF criteria
In Myanmar the ODF criteria includes:
1. No evidence of open defecation in the whole village.

2. Every latrine has a proper lid over the latrine pan and a cover on the ventilation pipe of the pit to
prevent flies.
3. Childrens faeces are disposed in the latrine pit or properly covered.
4. Everyone must wash their hands with soap or other soap substitutes such as ash or sand after using
the toilet, as indicated by presence of soap and water at the latrine.
The community should also prepare a strategy for sustaining the 100 per cent ODF status and an action
plan to carry this out, such as how it will mobilize and support the community to continue using latrines
and reduce the number of shared latrines.
In many countries, getting to this ODF point is achievement enough, and follow-up beyond 100 per cent
ODF status is left to Government health staff, with little in the way of formal monitoring and rectification
of any slippage.
Building in a post ODF process
Myanmar is trialling a process that shows promise for strengthening ODF sustainability, by closer
monitoring during the post ODF period and then rewarding the community for sustaining the status. The
theory is that a community can be supported and encouraged to adopt and continue positive sanitation
and hygiene practices through this additional step.
The timeline of the ODF process involves:
1. Village self declares ODF. Approximately six to eight months after triggering, if a community believes
it has reached ODF status, members of the village WASH committee check against the ODF criteria
by visiting all the households. When they are satisfied the criteria is met the committee contacts the
township (district) health office and requests an official independent verification.
2. External verification. An external verification team checks the compliance of the village with the ODF
criteria. Members of the verification team include: representatives from the Department of Public
Health (Central Health Education Bureau, and Environmental Sanitation Division) in collaboration with
the state/regional health education bureau, township medical officers, basic health staff, other local
governmental officials who are already trained as CLTS facilitators, and natural leaders from nearby
villages. The verification protocol involves sampling 15 per cent of households, carrying out physical
checks of latrines, interviewing households, and a transect walk through the village.
3. Interim ODF certification. If the village complies with the verification protocol then an interim ODF
status is awarded. This involves ODF declared villages attending a special ceremony at the Township
Medical office, which is also attended by the township authority, parliamentarians, township education
officer, basic health staff, CLTS triggered (but not yet ODF) villages and other ODF villages. This
ceremony is an opportunity for the sharing of lessons learned by ODF villages and non-ODF villages,
encouragement from the Town Medical Officer to non-ODF villages to become ODF, and for ODF
declared villages to maintain their ODF status. ODF villages also receive large signs that they
can display in their villages. ODF status is probationary for one year, during which time it can be
revoked if slippage occurs. For national monitoring purposes, villages are officially counted as being
ODF at this point.

4. Probationary ODF status. As part of their regular monthly visits to villages, Public Health Supervisors
and midwives include ODF follow-up. They encourage the community to continue using latrines and
maintaining other behaviours, build new latrines for those who are using shared latrines and avoid
reversion to open defecation. The maintenance of the ODF status is monitored and recorded on a
quarterly basis by the township authority and township medical officer. If they find non-conformance
with ODF requirements then the community status is revoked. A full award of ODF is granted after
maintaining ODF status for one year.
5. Full ODF certification. After one year of sustaining ODF, a village is certified as achieving full ODF
status.
Figure 1: Myanmars post ODF process
Interim Full
TRIG Community External

ODF Probationary ODF status ODF
GER self declares verification
6-8 months 12 months
Visit all households, Visual Survey of household Monthly coaching,

check ODF criteria latrines and HW (15%) encouragement,
OD check Transect walk monitoring
Household interview
faeces and HW behaviour Quarterly reporting
Child interview behaviour
WASH Verification Midwives/Public Township Medical

Committee Committee Health Supervisor Officer
Key issues
This process is yet to be adopted by Government and is only being trialled. In fact CLTS is not yet part
of the Governments approach to increasing sanitation and there are no authorized guidelines on CLTS
and ODF.
Implementers find that village ODF acknowledgement ceremonies should be held as soon as the
villages are declared ODF to keep community enthusiasm high. However, this requires strong
planning and coordination by township officers to ensure timing is suitable for ceremonies for batches
of ODF villages.
As yet, no village has implemented CLTS long enough to get to the full ODF status after the 12 month
probationary period.
The process has not been developed and described in detail beyond the probationary period. For
example, exactly how the full interim ODF status is verified and awarded is yet to be finalized, as is
the monitoring system for full ODF villages.
Regular follow-up by basic health staff is still weak because staff are overloaded with many tasks.
Implementers also do not have funds to conduct continuous monitoring after villages achieve ODF.

The trial of this approach will continue to be monitored by CLTS implementers and may soon find its way
into the Governments official CLTS approach.
One question remains what happens after full ODF status is achieved? Indications so far are that once
a community reaches ODF status that using a latrine becomes a social norm for villagers, and close
monitoring is not necessary. The key challenges are to move households away from using unsanitary
latrines to sanitary latrines, and to improve the sustainability of latrines in flood prone and sandy soil
areas where toilets are not durable and need to be frequently replaced. In these conditions, better
technical solutions and sanitation marketing could improve sustainability.

THE PHILIPPINES

Philippines: Closing the gap Using CLTS to fast track
sanitation for the poor in the Philippines
The sanitation problem
Access to improved sanitation in the Philippines has been increasing in rural areas since 1990, from 46
to 71 per cent in 2015, but open defecation is still around 10 per cent.33 It is predominantly poor families
that are disproportionally without access to sanitation. This is starting to change in the Philippines through
WASH integration in the core programmes of the Department of Social Welfare and Development
(DSWD) that directly target low-income households.
The target group
With support from The World Bank Global Water Practice Water and Sanitation Program (WSP), DSWD
is piloting CLTS and sanitation for 80,000 households through the Pantawid Pamilyang Pilipino Program.
Pantawid Pamilya is a social protection programme from the national government that invests in the
health and education of poor households with children aged 0-18 years old and/or pregnant women.
The Program supports the policy of the state to promote social justice, raise the standard of living and
improve quality of life for all.
Patterned after the conditional cash transfer scheme implemented in other developing countries, the
Pantawid Pamilya provides cash grants to beneficiaries, provided that they comply with the set of
conditions required by the programme. These include conditions such as pregnant women attending
pre- and post-natal check-ups, school enrolment and attendance, health check-ups, and attending
monthly parent counselling sessions. The Pantawid Pamilya also invests in human capital to overcome
future poverty and break the intergenerational poverty cycle. On average, 55 per cent of the 2.3 million
households registered in this programme do not have access to an improved toilet.
At first DSWD seemed an unlikely promoter of sanitation but WASH is a priority of the Department and
is included as a measure in its Social Welfare and Development Indicators (SWDI).34 Access of families
in the Program to sanitary toilet facilities is regularly monitored. In 2014, DSWD realized that it was not
making effective progress at increasing access to household sanitation, with results from the SWDI
showing that 584,373 households still had no access to any toilet facilities. The Philippines 2013 review
of scaling up rural sanitation also identified the Pantawid Program as a possible way for increasing access
to sanitation for the poor.
The main avenue for promotion of sanitation is through the Family Development Sessions. These are
monthly meetings between DSWD staff and 20-30 household grantees of the Pantawid Program.
Attendance at these regular one to two hour meetings at the barangay or village level is a condition of
receiving the DSWD cash grant. The topics covered aim to expand the knowledge and skills of parents,
and help them appreciate and comply with the health and education conditionalities of the programme.
The sessions also aim to strengthen family life and increase parent involvement in community
development efforts.
Sanitation and health have always been a topic in the Family Development Sessions, but usually involved
telling parents to look after their children and not let them defecate around the house.
Previously we were not focused on proper hygiene. Children go everywhere and dont mind
what germs they touch, so we would just say to parents, look after your children, keep them
clean, protect your children CLTS is more effective. I wish this project started earlier. Jehan
Lacandazo, Pantawid Program, Babatngon municiplality, Leyte province)
What the pilot changed
The pilot has strengthened the sanitation module of the Family Development Session by modifying the
content covered and making the style of delivery more participatory and engaging.
33 JMP (2015) Progress on Drinking Water and Sanitation, 2015 Update. World Health Organization and UNICEF.
34 Social Welfare and Development Indicators (SWDI) is an assessment tool that describes the socio-economic conditions in a family and measures its
level of functioning in terms of utilizing available internal and external resources to improve their quality of life.

Integrated into the enhanced Family Development Session now is:
The concept and urgency to stop open defecation;

The CLTS approach, in particular triggering using shock, shame and disgust to: build awareness on the
negative implications of open defecation, as well as its repercussions on health, especially on children;
and create demand for improved sanitation facilities;
Behaviour Change Communications (BCC), in particular a flipchart discussion or engagement session
to: (1) stress the unlimited benefits of having a toilet, and (2) to get commitment of Pantawid grantees
to build their own toilet; and
Promotion and offering of low cost or alternative designs of hygienic toilets.
These changes are integrated into more than one Family Development Session, with triggering done first,
then one month later at the next session, the BCC and latrine model options are introduced.
In addition to revising the content of the Family Development Session, a facilitators guide and BCC
materials were produced, DSWD staff trained, the concept pilot-tested, progress evaluated and
learning shared.
The Unli Asenso Pag May Inidoro (roughly translated means there
is unlimited progress when one has a hygienic toilet) Flipchart:
Handheld and Large Format.
Results are showing promise
Beneficiaries of the Pantawid Program realize that open defecation causes health problems, and
importantly, has cost implications in terms of medical expenses. Their strong reactions to discovering that
they are eating faeces include crying, and vomiting.
Within hours and days of triggering in Babatngon municipality in Leyte province, beneficiaries ceased
open defecation, began covering their faeces, sharing latrines with others, or using public facilities. Some
beneficiaries started to dig pits and build toilets. In another pilot in Quezon province, within four months
of the new approach in 10 demonstration municipalities, 3,298 beneficiary households have ceased open
defecation. According to DSWD staff, this is far more effective than the previous approach.
A Rapid Assessment in early 2015 was commissioned by WSP in the provinces of Negros Occidental
and Quezon to determine the initial outcomes of the integration of sanitation into the Pantawid Program.
Results have shown strong evidence on the impact of the enhanced Family Development Session
process:

Health Awareness Most of the grantees exposed to the enhanced Family Development Session
demonstrated a high degree of awareness on healthy water and hygiene practices. They were able
to associate unsanitary practices and unsafe water with prevalent diseases in their locality, i.e.
amoebiasis, diarrhoea, and helminthes. This awareness translated into increased household water
treatment and improved solid waste disposal practices.
Sanitation Facility Adoption Households triggered through the Family Development Session
adopted sanitation at rates of 17 to 29 per cent, depending on the municipality. The decision to
build toilets was driven mostly by social and emotional drivers, including: the protection of children
and teenage daughters, convenience and comfort, pride, health, and cleanliness.
Financing Grantees have employed various means to finance the construction of toilet facilities
including: setting aside a small portion of the Pantawid cash grant; accumulating savings from
income sources; and obtaining loans from relatives, employers, and hardware stores. Other
grantees were recipients of traditional Local Government Unit subsidies for toilet bowls or
construction materials.
Links with other DSWD Programs
DSWD recognizes that the Pantawid Program alone cannot transform households PILOT
out of poverty. In 2014 DSWD developed a new framework to integrate DSWDs
three big programmes, namely the Sustainable Livelihood Program,35 the Kalahi-
CIDSS-National Community Driven Development Program,36 and the Pantawid
4
Regions
Pamilya. DSWD has convergence officers at municipal, provincial and regional
levels to operationalize how these programmes can be brought together to enhance
their effectiveness. 11
Provinces
For sanitation, the links with other programmes provide a way for poor households
in the Pantawid Program to gain skills, tools, money, and community support to
end open defecation and build toilets. Through the Sustainable Livelihood Program,
31
Municipalities
Pantawid beneficiaries can access:
skills training in the areas of masonry, plumbing and carpentry; 891

Barangay
cash for work programmes which provide 11 days of work including on toilet
building projects; and
loan funds of 10,000 pesos for self-employment assistance. This is an
80,210
Households
opportunity for masons to pool funds and manufacture latrines for other
beneficiaries or sell to the local government.
For the Kalahi-CIDSS programme, WASH projects (including sanitation) are one of the choices on the
menu of community projects that can be funded by the programme. The programme follows a defined
project cycle that promotes strong stakeholder participation starting with the identification and selection
of community sub-projects.
Challenges
A very different approach
One of the biggest challenges has been the acceptance of CLTS by DSWD facilitators who are used to a
different style of engagement.
35 Sustainable Livelihood Program (SLP) is a community-based capacity building programme that seeks to improve the programme participants socio-
economic status. It is implemented through the Community Driven Enterprise Development approach, which equips programme participants to
actively contribute to production and labour markets by looking at available resources and accessible markets.
36 Kapit-Bisig Laban sa Kahirapan-Comprehensive and Integrated Delivery of Social Services-National Community-Driven Development Program (KC-
NCDDP), is the expansion into a national scale of operations of the community-driven development (CDD) approach, a globally recognized strategy
for achieving service delivery, poverty reduction, and good governance outcomes. These are realized by helping communities identify challenges in
their locality, and making informed decisions on a range of locally identified options for development.

At first I experienced some difficulties in doing CLTS. The normal Family Development Session
is a very different approach you have to be very nice, very approachable. In CLTS you have to
be strong, you have to make people realize they should have a latrine. If you cannot be effective
as a facilitator you cannot touch their lives, their emotions, their knowledge, and then you cannot
change the way they think. After two or three times it started to come naturally. Christina Lim,
Pantawid Program, Macalelon, Quezon province.
Pantawid Program staff themselves initially experienced shock, shame and disgust doing the CLTS
triggering in open defecation areas, but are now getting used to dealing with tae (faeces). Their own
improved awareness of the transmission of disease through flies and faeces has spread to their personal
lives and families and also to their colleagues in other programmes.
The participatory style of CLTS triggering has also influenced some staff in the way they conduct other
Family Development Sessions. Open forums with discussion and sharing of solutions are more common
because of learning from the CLTS style.
Maintaining relationships with beneficiaries
When the piloting of CLTS was first discussed, a major apprehension of DSWD senior staff was the
possibility of alienating people in disadvantaged situations and damaging long-standing relationships
with beneficiaries. Pantawid staff build up rapport with beneficiaries over one or two years of regular
contact, but the different approach of CLTS was initially confrontational; DSWD feared that the approach
would break these relationships and triggering would require sensitive handling. CLTS triggering has in
fact brought back community pride and a consensus to stop open defecation. The process has proven
effective through the use of humour community participants laugh about the topic and shaming is
subtle. Some facilitators feel the need to further protect the feelings of beneficiaries, by explaining the
necessity of going through the CLTS triggering process and the importance of sanitation that needs to
be addressed to reduce the effects of poor sanitation and malnutrition on children. After CLTS triggering,
staff go back to the community for monitoring, and for other Family Development Sessions, so for some
facilitators this session closure is needed.
Can the poor really afford toilets?
The Pantawid Program grant does not provide cash or credit for latrine construction. The small monthly
grant (a maximum of 2,000 pesos or US$ 44 per month) is for immediate needs such as education
and food. Access to money to build a latrine, especially a septic tank toilet in high water table areas,
is a challenge for beneficiaries, particularly the 30 per cent of beneficiaries who are at poverty level.
A household with any available savings is faced with competing priorities of whether to pay off long-
standing debt, set aside funds for special occasions or emergencies, or build a toilet. The capacity to
purchase the necessary materials to build toilets remains an ongoing challenge, however some creative
approaches are being used to work around this:
Savings of beneficiaries from the Pantawid grant money and from informal work some beneficiaries
are able to save small amounts of money towards a latrine. Usually this is through practicing daily
savings of 1 or 2 pesos (US$ 2-4 cents) which is put aside in a coconut shell or a piece of bamboo,
and quarantined from regular household spending.
Loans some beneficiaries with a capacity to repay, borrow money from friends and neighbours.
Community support during the Family Development Session beneficiaries are encouraged to help
and support each other. For example, if one beneficiary is not able to dig a pit they can call on other
parent group members to help.

Grants from local government Very poor beneficiary households without capacity to build a toilet,
such as a solo mother with many children, or an elderly couple, are helped by DSWD to link them to
the local government unit for financial assistance with materials. Young, able-bodied beneficiaries are
expected to self build.
Smart subsidies The DSWD may negotiate a bulk price at a hardware provider, thus reducing the
materials cost; or the local government may be persuaded to provide a truck for the transport of
materials to beneficiary homes, saving on transport costs.

This Pantawid beneficiary gave up smoking and
used the money to save for a latrine.
Sustainable Livelihoods Program Through this DSWD programme beneficiaries can be trained as
masons, earn short-term wages and potentially be organized as a local enterprise supplying sanitary
products and services to their community.
Kalahi-CIDSS Program Priority for barangay sanitation is identified during the community
participatory process of this DSWD programme. However, due to limited resources, sanitation may
drop off the priority list presented at the Municipal Inter-Barangay Forum if other barangays have more
pressing issues.
Making coordination work is hard work
Internal coordination between DSWD programmes and externally with other agencies, such as
the Department of Health, is a constant challenge, and requires special effort, particularly at the municipal
level.
DSWD programmes have different implementation schedules, especially the community driven
development cycle of the Kalahi-CIDSS and the monthly parents meetings of the Pantawid Program.
Optimally, CLTS triggering should occur just before the first barangay assembly of the Kalahi-CIDSS in
which the need for the construction of toilets to be funded as a subproject for Kalahi-CIDSS is identified.
If the schedule does not align then the need for the construction of toilets for triggered beneficiaries does
not get picked up.
To improve timing and sequencing, DSWD programmes share their work schedules through Municipal
Action Team meetings. During these meetings core DSWD programme representatives discuss plans and
activities for the next days, weeks, and months. Local priorities and needs are identified and agreement
reached on who is doing what and when. For example, if Kalahi-CIDSS is planning to conduct barangay
assemblies in July, then Pantawid staff arrange their schedule to trigger beneficiaries in June.
Coordination with outside agencies is more challenging, but there is a forum at the municipal level for this
to occur. Municipal Inter Agency Coordination meetings are held monthly with all agencies and the local
government. This is an opportunity to discuss local issues with partner agencies, and update each other
on progress, and needs. However, a challenge is that DSWD staff rely on the attendance and availability
of partner agencies for that coordination to occur. Other ways of coordinating with outside agencies are
through personal contact and building relationships. For example, Pantawid staff work closely with nurses
to coordinate health checks with triggering on the same day; or invite rural sanitary inspectors to attend
triggering and other events.

Support of political leaders essential for scaling up
Support of the Municipal Local Chief Executive or mayor can make a huge difference to the speed and
uptake of CLTS for both Pantawid and non-Pantawid households and achieving Zero Open Defecation
(ZOD) communities. When mayors are very open and supportive to improving sanitation, progress can be
rapid and comprehensive. In the Lucban municipality in Quezon province, DSWD staff have been able to
push the local government to embrace the WASH programme for the whole municipality, with everyone
triggered. This has resulted in only a small number of people without a toilet facility and the prospect of
achieving ZOD within reach in 2015.
Although Lucban municipality has a male mayor, DSWD staff say that it is often female mayors who are
most supportive of achieving ZOD.
Many other mayors are indifferent and do not prioritize sanitation as an issue in their community,
especially those that have won awards for a clean environment. Often it falls on DSWD staff to lobby the
mayor to take care of other non-Pantawid households and prioritize sanitation and ZOD.37 This involves
many presentations at the municipal level to sell the idea, highlight needs and achievements, and then
regular follow-up visits and consultations with feedback to mayors on the progress. Staff generate a
little competition by comparing progress between municipalities. The strategy to win over local leaders
is demanding on DSWD staff time. Staff are both daunted and optimistic about the prospect of an
election in 2016 it will mean repeating the consultation process for new local leaders, but it provides an
opportunity for a fresh start and a chance to get local leaders on board early.
Land is not always available
WSPs rapid assessment found that a number of grantees were landless and not permitted to build
permanent structures on the land they were living on by the landowner. In Typhoon Yolanda (Haiyan)-
affected areas many people live in temporary or transitional housing and are awaiting relocation to
permanent housing or live in informal settlements. Even in these areas landlords often do not agree to
the construction of latrines on their land. Some beneficiaries in Yolanda-affected areas are holding off
building a toilet until they are relocated, but they are currently digging and covering faeces. In Babatngon,
solving the problem of open defecation was discussed at a barangay council meeting where it was
resolved by an offer to donate land to build community toilets.
This is just a pilot isnt it?
The potential of DSWD to contribute to the national goals for ZOD is not yet fully appreciated by the
DoH or integrated into the National Strategic Sanitation Plan. The pilot is seen as a separate activity from
the efforts of the DoH. This may change in time with more evidence and consultations on how the two
departments can work together strategically and practically. There is also an on-going initiative among
national agencies, including DSWD and DoH, to establish the National Inter-Agency Committee for Rural
Sanitation to coordinate and jointly implement WASH initiatives.
Criteria for pilot site selection

REGIONAL
The top four regions with the highest incidence of households without access to sanitary toilet
facilities and safe water.
MUNICIPAL
Areas where three DSWD programmes are integrated

30 per cent or greater incidence of households without access to toilet facilities
25 per cent or greater incidence of households without access to safe water
Improving the level of well-being of 2.3 million Pantawid Pamilya participants
37 The Municipal Health Officer of DoH is expected to trigger non-Pantiwid beneficiaries.

What works:
WASH is already a priority for DSWD in its programmes. The integration of the three core DSWD
programmes means the opportunity for sanitation is being optimized through the DSWDs
convergence.
Focusing integration at the municipal level and strengthening staff is where the action is. The
Municipal Action Team monthly meetings provide a formal mechanism for essential coordination.
CLTS has a captive audience. It is compulsory for Pantawid beneficiaries to attend Family
Development Sessions where they are exposed to CLTS triggering.
CLTS simple and experiential triggering approach is very suitable for beneficiaries, many of whom
who have no schooling.
Many of DSWDs municipal staff are young professionals with backgrounds in social welfare, teaching,
and nursing. They are energetic and independent, but as with all department staff, are motivated to
deliver results due to employment on one-year performance based contracts.
Close regular monitoring by DSWD means that the effectiveness of CLTS in stopping open defecation
is obvious. This information is an important tool to demonstrate results to municipal mayors.
A DSWD Guidance Note clearly outlines how the integration of the three programmes works at all
levels.
Lessons learned:
Non-traditional advocates of sanitation promotion and CLTS triggering can be as effective as traditional
ones. DSWD has proved it can increase sanitation access, despite only recently becoming an
advocate.
CLTS is a new approach with which DSWD staff take time to become familiar.
Coordinating and integrating three different programmes requires a concentrated effort and clear
operationalization of what integration means in practical terms.
Staff support and training is essential at all levels of the Department, from the national level through to
implementing staff at the municipal levels.
Advocacy to local government, especially mayors, is critical to the success of community sanitation.
The biggest learning from Quezon is that we cannot do things alone. It has to be a collaborative
and coordinated effort, and the dedication to achieve something. Marilyn Barrameda, Provincial
Link, DSWD Quezon province
Future outlook
The WASH integration in DSWDs convergence pilots is only at an early stage and although initial results
are promising it will not be rolled out to other provinces, municipalities and barangays until June 2016.
The next step will be to reflect on the learning so far and strengthen the approach.
Areas for further consideration include: consistent guidelines on funding of sanitation; advocacy
processes and approaches; sanitation marketing; sanitation inclusivity; and involving people with
a disability.
Preparatory
Phase
(policy and materials
development)
Learning
Phase
(intensive handholding, process building, and standardization)
Universalization
Phase
(rollout)
JAN JUN JAN JUN

2015 2016

Philippines: CLTS in post emergency situations Philippines
How can CLTS fit within a post emergency situation when people and Government are recovering from
widespread devastation and disruption? Experience from the Philippines following Typhoon Haiyan in
2013 shows that it is possible when part of a larger strategy to address sustainable sanitation.
Background to the emergency
Around 2 a.m. on 8 November 2013, Typhoon Haiyan (or Yolanda as it is known locally) made landfall in
the Philippines. It was one of the most powerful and destructive typhoons ever recorded, with winds
travelling at hundreds of kilometres per hour and a massive 5-6 metre storm surge that swept through
low-lying coastal communities.
The Philippines is no stranger to tropical cyclones or typhoons, with 20 entering the countrys Area of
Responsibility each year and of these usually six to nine make landfall. Despite storm warnings and
preparedness, Typhoon Yolanda resulted in more than 6,000 people killed, and houses, schools and health
centres flattened. Some 14.1 million people were affected. Over 4.1 million people were displaced,
including 1.7 million children. Those hardest hit were on coastal and inland areas of Biliran Island, Eastern
Samar, Leyte, Northern Cebu, Metro Cebu, Samar, and Southern Leyte. Tacloban city, in Leyte province
had 90 per cent of its buildings destroyed or damaged. Before the typhoon hit, these communities were
among the most vulnerable in the Philippines with 40 per cent of children living
in poverty.38
The Government of the Philippines mounted an immediate response to deliver life-saving relief, with
assistance from the United Nations. UNICEFs Emergency Procedures for a Level 3 emergency were
triggered and the cluster system of coordination, co-led by the Government and United Nation agencies,
was also immediately made operational. An Inter-Agency Strategic Response Plan (SRP) was developed
and run from November 2013 to November 2014.
As co-lead for the WASH cluster, UNICEF coordinated national efforts for disaster relief relating to water
supply, sanitation and hygiene and related efforts to transition to development. In an emergency the
initial response is to meet immediate lifesaving and medium term WASH needs for the most affected
people. For sanitation this involved UNICEF engaging in or contracting humanitarian NGOs to construct
emergency latrines in affected areas, and provide and operate portable toilets in camps reaching 310,000
people by the end of the SRP in November 2014. After life saving needs were met, UNICEF supported
the development of a longer-term government-led holistic recovery and sustainable sanitation strategy
in the Yolanda-affected area covering three regions (6, 7 and 8), six provinces, 47 municipalities, 874
barangays or villages and with the aim of reaching a total of 1 million people.
The strategy to address sanitation in Yolanda-affected areas
The Philippines WASH Cluster, including the Departments of Health (DoH) of affected regions, developed
a Sanitation Strategy for Early Recovery in Yolanda-affected areas based on the rural sanitation strategy
concept that existed prior to Yolanda. The Phased Approach to Total Sanitation (PhATS) is designed to
help the national government achieve the goals of the Philippines Sustainable Sanitation Roadmap and
the National Sustainable Sanitation Plan. These goals include that all barangays (villages) be declared
Open Defecation Free by 2022, and all Local Government Units (LGUs) have their own local sustainable
sanitation plans and budgets in place under the Investment Plan for Health by 2022.
PhATS builds on these national objectives to create an open defecation free environment with the
safe disposal of liquid and solid wastes through a phased and holistic approach. PhATS combines the
interrelated pillars of demand creation, with supply side interventions, and improvements in the enabling
environment.
38 UNICEF (2014), One Year After Typhoon Haiyan, Philippines Progress Report.

Figure 1: PhATS holistic approach
The enabling environment pillar aims to develop the capacity of LGUs and governance at the regional
and provincial level, including DoH and Department of Education, to understand, own and trigger PhATS.
This pillar specifically aims to: improve WASH policy and planning, strengthen decision-making, increase
accountability and transparency of processes and duty bearers, effectively allocate budget for sanitation,
improve sector coordination, and increase monitoring capacity. Comprehensive governance training and
engagement is provided to achieve this. The enabling environment also includes generating knowledge
and information to improve performance.
The community demand creation pillar is divided into three main stages: pre-triggering, triggering and
post-triggering. These stages aim to: identify expectations, generate the accountability of barangays
through the participatory development of action plans and the discussion of sustainability, and trigger
community members to recognize the need to change hygiene and sanitation behaviours, particularly
stopping open defecation and achieving Zero Open Defecation (ZOD)39 barangays. A range of approaches
to sanitation and hygiene demand creation at community and household levels is acceptable, including
tools such as Community-Led Total Sanitation (CLTS). School demand creation aims to develop children
as messengers of change at home and school by targeting at least one school in each barangay for cash
transfers, with capacity development for the Department of Education.
The supply pillar aims to strengthen local supply chains for sanitation and hygiene goods and services,
encourage sanitation marketing, and develop the regulatory, monitoring and support functions of the local
government. This pillar also includes the development of financing mechanisms for household credit, and
working capital loans to local sanitation producers and service providers. Support is provided to partners
to develop at least one decentralized wastewater treatment system, which can be used as a model for
replication.
Phased approach
The PhATS implementation strategy is designed to overcome weaknesses of conventional sanitation
interventions that just focus on building facilities or completing behaviour change activities, without
planning for follow-up activities, or improvement of facilities and practices over time.
PhATS also takes account of the heightened needs and limited human resource capacities that exist
within the first three to six months of a large scale emergency response and breaks down the early
39 Zero Open Defecation (ZOD) is the local term for Open Defecation Free (ODF).

recovery process into several phases. Each of these phases requires the achievement and independent
verification of defined and measurable outcomes, before graduation to the next phase (or Grade). The key
entry point is achieving ZOD status using a common framework.
Figure 2: PhATS implementation phases
For a barangay to achieve ZOD status (G1) it must have excreta-free open spaces, drains and bodies of
water, 100 per cent use of hygienic toilets (up to 20 people per toilet), and safe child excreta disposal.
The WASH Cluster agreed that the G1 process should also include some minimum activities to
address behaviour change, build capacity within the LGUs, and share learning between the different
stakeholders and partners. These include: use of demand creation tools; involvement of school and day
care centre WASH stakeholders in the community processes; minimum health and hygiene promotion;
barangay baseline sanitation survey; barangay sanitation plan for ZOD achievement; barangay sanitation
committee; barangay health worker training; a ZOD verification and certification process; and knowledge
management activities.
Once the barangay is open defecation free, it self-declares ZOD status and requests verification by the
municipal Sanitary Inspector and Provincial Health Office representative, resulting in the barangay being
awarded ZOD certification. Following an agreed official monitoring procedure, the Sanitary Inspector
follows up on the status of ZOD and reports back to assure sustainability of results.
A difference with the phased approach of the Rural Sanitation Strategy being implemented in other parts
of the country and the Yolanda Recovery is that the subsidy of sanitation hardware is permitted. This is
because of the devastating and economically challenging conditions created by the typhoon, particularly
for very poor households without toilets prior to Yolanda.
No specific demand creation approaches or tools are prescribed to reach ZOD, but NGOs and LGUs
are encouraged to draw from a toolbox of demand creation approaches and tools, and training in key
approaches like CLTS are also made available. How NGOs and LGUs apply demand creation tools is
flexible; allowing for innovation, and application of their own capacities and experiences from elsewhere
in the Philippines and the region. Efforts are made to monitor, evaluate and share best practices across
partners, as a way to spur the evidence-based improvement of approaches.
The phased approach is supported by incentives (both financial and non-financial) that encourage and
reward the achievement of each grade. Partners are taught on how to apply subsidies and incentives,
and while the subsidy amount is generally fixed,40 partners have the flexibility of when and how to apply
subsidies.
40 The value of subsidies was fixed at PS 6,000, with higher subsidies only allowed in low water table areas.

Progress and results
The Philippines had experience in CLTS implementation prior to Typhoon Yolanda. UNICEF, World Bank
WSP and Plan International each had its specific implementation approach, but at a very limited scale.
According to a 2013 report on scaling up rural sanitation, there were only around 50 ODF communities,
and fewer than 250 barangays triggered after five years of CLTS implementation (in a country with 42,000
barangays).41
As of May 2015, more than 400 barangays or nearly half of all 874 barangays in 47 municipalities across
the Yolanda-affected area have been verified as ZOD at G1 level.42
How did these disaster-affected areas get to ZOD in just 18 months after Typhoon Yolanda?
After the initial emergency response following Typhoon Yolanda people moved back to their homes and
communities much faster than expected. This provided an opportunity to use existing systems and build
on research and past thinking from the previous years of CLTS implementation in the Philippines. The
idea was to test experience on whether it was possible to do a participatory demand-led approach within
the context of an emergency in the Philippines.
One of the biggest challenges to implementing CLTS in the post emergency situation has been changing
the mindset of emergency implementers to a developmental approach. Immediately after the emergency
UNICEF made humanitarian response Partnership Cooperation Agreements (PCAs or contracts) with 12
international NGOs which ran until August 2014. The PCAs did not have targets for ZOD or even mention
CLTS or demand-led approaches as they were standardized humanitarian PCAs targeting life saving needs.
Most of the staff from NGOs working on the Yolanda response had never been exposed to the ZOD
concept or done CLTS before, however, they were used to supplying latrines in emergency situations.
The idea of CLTS and ZOD was slow to take hold. During a WASH cluster meeting, at the end of
November 2013 UNICEF began discussing open defecation free communities as an outcome (consistent
with national policy) rather than just supplying sanitation. In the beginning this elicited a strong negative
reaction from the emergency group, with some NGOs simply saying they do not do CLTS. UNICEFs
dialogue with humanitarian NGOs continued through early 2014, eventually an informal commitment was
agreed that all of the 12 NGOs should try to get at least two barangays to ZOD in the Yolanda-affected
area. NGOs committed to this goal, despite no contract requirement to do so, and began using demand
creation and social mobilization in their approaches. To support this, UNICEF provided condensed two-day
demand creation training for all humanitarian PCA partners in April 2014.
The thinking behind the target was that if the 12 NGOs committed and started with a small doable target,
then they could do one barangay, then two and possibly many more. It turns out that this is exactly what
happened. By the end of the strategic response plan (end November 2014) 84 barangays had achieved
ZOD more than three times the expected 24.
Supporting Government to accelerate progress
The Government has a critical role to play in supporting and sustaining sanitation beyond the recovery
phase. Consultation took place with DoHs in all affected provinces to get feedback on how to move
forward from the emergency response to development.
In order to shift to large scale development, UNICEF knew that work had to start immediately on
governance and the ability of local governments and sanitary inspectors to understand what demand
creation was. Under a separate interim PCA agreement (from April 2014), the NGO A Single Drop for Safe
Water developed a training module and began providing five-day training sessions in demand creation and
other training in governance (including how to develop a WASH plan) for mayors and key players in LGUs.
At same time in June 2014 UNICEF developed partnership agreements with 40 LGUs where UNICEF
funded targeting of sanitation improvements using direct cash transfers through Government systems
to test and strengthen the governmental funding flow. Although seen as risky by some, direct cash
41 Robinson, A. (2013), Development of a multi-stakeholder implementation strategy for scaling up rural sanitation - Final report, UNICEF.
42 PhATS Newsletter Volume 1 Issue 2 May 2015.

transfers channelled funds and expenditure using Government procedures and mechanisms, helped build
capacity at different levels and make the Government central to decision making about how money was
spent. Achieving ZOD barangays was written into the contracts with the LGUs, and with training from
UNICEF on governance, demand creation and technical aspects it was then up to each LGU to use their
own mechanisms to get their barangays to ZOD. This supports a long-term development approach where
in the future the Government could use its own funds to implement a Government programme and even
hire NGOs.
Almost all direct cash transfer PCAs were completed in June 2015, and while a detailed analysis is yet
to be undertaken, the results have been mostly positive. Using expenditure as an indicator of success,
a number of LGUs have spent all their funding and are able to use other funding streams within the
bureaucracy of the municipality to reach higher sanitation goals. Some municipalities have allocated
additional funding for WASH into their annual investment plans, while some have developed WASH plans
which clearly tackle ODF in their communities.
Since September/October 2014 the UNICEF team started shifting to the next level of governance and
began working with Provincial Health Officers and the DoH at regional level to scale up.
Formalizing NGO commitments to ZOD
As the end of the humanitarian PCAs loomed in August 2014, UNICEF was keen to push towards
development and build on the ZOD achievements made informally by humanitarian NGOs. Following
comprehensive discussions with Government in all provinces, UNICEF teams, and with humanitarian
partners on how to take the early recovery phase into a development programme, new standardized
development PCAs were devised. The PCAs covered 874 barangays, and included ZOD targets
embedded in a standardized approach which all PCA partners had to follow. The development PCAs
encompass 12 NGOs (many from the emergency phase) and run from September 2014 until November
2015 with a possible three month extension.
One NGOs perspective
An example of one of the Yolanda NGOs that has fully taken on board the PhATS approach is Samaritans
Purse. Although not one of the original humanitarian NGOs contracted by UNICEF, a major component
of Samaritans Purses Typhoon Yolanda relief strategy was a large-scale sanitation project, which saw
11,700 household latrines (with septic tanks) constructed across two municipalities in Region 8. This
involved the supply of free materials in different stages, contracting skilled masons, with households
contributing labour. Since then Samaritans Purse has moved away from subsidized approaches, and is
facilitating demand creation, linking with micro finance organizations, strengthening the supply chain
through developing technical skills and business acumen of local entrepreneurs, and sanitation marketing
promotion, as well as supporting the design of septage treatment facilities.
In terms of demand creation, Samaritans Purse follows the general process of pre-triggering to post-
triggering process. However, it has found that in the post emergency situation there are some people
in the community who were waiting for handouts from international NGOs. To overcome this it is made
clear at the outset that there is no special handout according to Beverlely Holares, one of the Hygiene
Promoters. We make it clear from the very beginning that we are now in a recovery phase. We tell them
we are visitors in their place and we have nothing to give, and we are here to talk to them, ask how they
are doing, about their situation. We set the environment, and set proper expectations.
Samaritans Purse has found that the speed of reaching ZOD from triggering is increased significantly
when two people from each barangay are appointed as PhATS advocates. These people are involved from
the beginning and receive training for three days in all the CLTS and PhATS processes, and activities.
Most PhATS advocates are barangay officials or barangay health workers. During triggering PhATS
advocates take an active role and participate as environment setter, lead facilitator, core facilitator, or
process recorder. The results from Basey municipality43 highlight this effect the time from barangay
triggering to submitting a letter for verification of ZOD is just two to six weeks.
Lessons learned
43 Basey municipality has 52 barangay.

Why has the PhATS approach worked after such a devastating emergency? What are the lessons
learned?
Do not conduct CLTS during the height of the emergency. In the critical emergency phase CLTS
is not a suitable approach to sanitation; an immediate life saving response is needed for six to eight
weeks, possibly up to 12 weeks after the emergency event. During this time it is not possible to talk
about community mobilization as no one is open to the idea. The appropriate sanitation response is to
construct emergency latrines in communities and emergency centres.
Shift to development as soon as possible. There is a huge opportunity immediately after an
emergency to take the energy, initiative and openness of people and Government to shift into a
large-scale development programme which innovates and tests ideas. The transition to a development
phase should be made as soon as possible after the emergency peak period.
A large budget. Having a large budget available as a result of the emergency allows for both
experimentation/innovation and scale. Before Yolanda, UNICEF WASH pilot projects included CLTS
in barangays, but the total development programme budget was extremely limited (less than US$ 4
million per year). Yolanda had US$ 40 million WASH programmatic funding (not including staff) US$
20 million which was for humanitarian work and a further US$ 20 million for development.
Consult regularly with partners. Changing mindsets and introducing new approaches requires a
lot of ongoing discussion and joined learning. Monthly PCA partner meetings were held to share
experiences and allow for learning on PhATS step by step over time by people from humanitarian
backgrounds. Joint development of the large scale development programme with PCA partners and
government required ongoing discussions. This process, especially feedback and involvement from
Government should begin as soon as possible.
Have flexible PCAs. UNICEF provided the strategy, training, and tools for PhATS and achieving ZOD
communities. Although the development PCA was standardized between NGOs, it did not prescribe
in detail what approach NGOs were to take and what they had to do on a daily basis, but only that
there were targets for achieving ODF. This kept ownership of the process with NGOs and allowed for
innovation in the way they set about reaching their goal.
Build on existing approaches and existing policy. Whether CLTS can be applied in a post
emergency situation depends on the policies existing within the country for a development
programme at that moment. PhATS builds on the existing policy and directives of the DoH in achieving
ZOD communities. CLTS had also started to be used in a conflict area in Mindanao with positive
experiences. The same three-phase sanitation development framework outlined for the rural sanitation
implementation strategy was applicable for PhATS for Yolanda Recovery but with some adaptation
for context and integration with the successful strategic approaches utilized by humanitarian actors
working on the early response and recovery.
Build capacity of government as soon as practical. From the outset there was a focus on
governance and training the different entities at government levels about PhATS. This training can
start early, even just six months after the emergency. Although this sounds early, in the Philippines six
months after an emergency typhoon is six months before the next one. For Government, typhoons
are part of a continuous annual cycle and do not present any particular barrier to improving capacity.
Get national level endorsement. DoH was hesitant about the phased approach to total sanitation,
but the emergency gave the impetus to try the approach, and DoH was willing to support it in affected
areas. A very detailed Mid Term Review process, which was joined by national level DoH, showed
how the national policy on sanitation fitted into the PhATS, and that PhATS provided a methodology
to operationalize the national policy. This led to DoH staff confirming that the approach did support the
Philippines sanitation policy.
Institutionalize ZOD criteria and verification process. Institutionalizing the ZOD criteria ensures
standardization of measurement, as well as local government buy-in. In the Philippines it is usually
essential to have municipal or regional ownership and endorsement of a programme to get anything
achieved. However, because of the emergency context, the PhATS concept and ZOD monitoring
system was jointly discussed and agreed with all provinces, and able to be implemented without
formal approval. Later UNICEF helped to retrospectively formalize PhATS and ZOD through a
memorandum issued G1 and G2 certification in Region 8 building on existing national guidelines.
UNICEF is now working with Region 6 on the verification process.
Employ knowledge management to share experiences. UNICEF made a special effort to develop
tools and systematically document what was being done in order to share learning between PCA

partners. This is being done through a contracted NGO to consolidate NGO experiences, and a senior
sanitation specialist to document technical findings from the field.
What has been learnt about what could be done better?
The understanding and application of subsidies, rewards and incentives by NGOs could be
improved. The approach has been an open one, with NGOs choosing whether they offer subsidies and
rewards before or after ZOD. However, better targeting of the very poor is needed and more thought
about when it is best to support them.
Overall lessons need to be drawn from the many different approaches to achieving ZOD employed
by NGOs and LGUs. A second implementation cycle should take these lessons into account and apply
them within a tighter implementation framework.
NGO staff and Government would have benefitted from more quantity and depth of training,
however the capacity for people to take up new learning after an emergency is an issue. NGO staff
turnover was also a challenge for capacity development.
Strengthening advocacy and greater use of media campaigns to reinforce the overall messaging of
PhATS and to increase dissemination of the approach.
Next steps for sanitation in the Yolanda affected area and nationally
Perhaps the most promising outcome from the Yolanda experience is the institutionalization of ZOD
within local government systems. Governance work aimed to secure additional allocations into the
WASH budget line at the local government level and there are signs that budget allocation is increasing.
With skilled NGOs available, it is hoped that NGOs will one day be engaged by LGUs using their own
resources to achieve ZOD of all barangays.
In the meantime UNICEF is continuing to build on partnerships with Government entities to strengthen
Government units at provincial and municipal levels, with the aim of expanding the roll out of PhATS with
the objective to declare additional barangays ODF. UNICEF is also providing funding to DoH and Provincial
Health Offices to establish a much needed national monitoring system for tracking and analysing ZOD
achievement and sustainability, with Region 8 selected as a pilot to develop the monitoring system. This
pilot could very well serve as a springboard for DoH in establishing and systematizing a ZOD information
and monitoring system at the national level.

SOLOMON ISLANDS

Solomon Islands: CLTS in urban areas: Informal settlements in
the Solomon Islands
Across Melanesian cities, WSP estimates that between 20 and 45 per cent of the urban population lives
in informal settlements with poor access to WASH services.44 These are unplanned residential areas that
have developed outside of the formal urban planning rules of a city, often in physically marginal or peri-
urban areas, with uncertain or illegal land tenure, minimal or no services such as water and sanitation,
and a lack of recognition by formal governments. In Honiara, the capital of the Solomon Islands, at least
35 per cent of people live in settlements.45
World Vision is implementing a programme to improve WASH services in five informal settlements
around Honiara in order to improve the health and safety of residents. The settlements vary dramatically
in their physical environment, size, land tenure, social cohesion, and cultural practices. Each settlement
is home to between 800 and 4,000 people and they are well-connected by transport to the city, with
many people working in the urban cash economy. World Vision has complementary programmes in each
of the settlements focused on promoting youth employment and reducing gender-based violence. Each
settlement has a Community Facilitator and an Assistant Facilitator employed by World Vision to work
across programmes. The Assistant Facilitators are from the settlements.
Prior to CLTS, the sanitation conditions were either basic unsanitary pit latrines which were self built
without any technical expertise and are shared between multiple households; or open defecation in
bushes, creeks, or the ocean.
One of the objectives of World Visions programme is to pilot CLTS methodologies and contextualize
CLTS for Honiara. Paul Amao, Project Coordinator for World Visions Honiara Urban WASH Program says:
It is not a matter of transplanting rural CLTS into an urban setting. To increase the success of their
programme, World Vision has modified CLTS approaches and messages depending on the context of
each settlement.
Compared to rural villages, it is more difficult to get participation in CLTS triggering events because
residents are often working in Honiara and spend long periods of the day away from home. World Vision
has learned that the best time to conduct CLTS triggering is in the afternoon or later part of the day when
more people are back in the settlements.
It is much harder to implement CLTS in urban settlements that are a melting pot of people from different
ethnic groups living together. World Vision has found greater success with CLTS in peri-urban areas
where there is a single ethnic group, similar to a rural community. To overcome the lack of unity, World
Vision works with church and natural leaders, and helps set up and empower WASH Action Groups or
Committees in each settlement. Usually five men and five women are in the Group, although this varies
by settlement. The members are selected after community CLTS triggering, based on their interest and
availability.
The function of the WASH Action Group is to mobilize the community and facilitate action to improve
the WASH situation in the settlement. These WASH Action Groups motivate and monitor community
progress, working with World Vision to develop and implement monthly action plans to tackle the
problem. One challenge is that attendance, especially by women, is inconsistent due to other
commitments and duties. Another challenge is that in urban settings, members of the WASH Action
Group sometimes expect or demand cash stipends or compensation for their participation.
In dense urban areas, simply covering faeces is not a suitable sanitation solution. Having a toilet is
important for privacy, convenience, womens safety, and health benefits. Even though there is access to
a sanitation supply chain outside of the settlements, the cost is a barrier to residents on low and often
irregular incomes. Even local bush materials such as palms, and recycled materials must all be purchased
outside the settlement and transported to the community at a cost.
44 World Bank-WSP, 2015, Delivering Water and Sanitation to Melanesian Informal Settlements: Solomon Islands, Fiji, Vanuatu, Papua New Guinea.
45 ibid.

World Vision is helping settlers gain access to toilet products by linking with the Honiara City Council.
Honiara City Council has been manufacturing low cost, improved sanitation products for more than 18
years and selling these to the public at a small loss. Toilets are made of concrete with a fiberglass water
seal, but the toilets are heavy and bulky, so it is very difficult and expensive for an average person to buy
a toilet and transport it back to their home. Households prefer raised toilets, but these are very expensive
at SBD 600 (US$ 75) each. Squat toilets are much cheaper, at SBD 120 (US$ 15) each.46
On behalf of settlements, World Vision places combined orders of slabs and construction materials
with the City Council and then supports the cost of transportation of the order to the five Honiara
settlements. The size of the order depends on each community, with an average order around two to
four slabs. Without this support, residents in peri-urban settlements like Burns Creek would have to pay
an additional SBD 200-300 (US$ 25-38) to get their toilets home. The community also receives training
in how to make slabs and cement risers using molds. World Vision has assisted some areas by providing
access to free construction materials, like used tires that could be used for lining pits. By facilitating
orders for materials and toilets through the City Council, World Vision is helping to maintain the low cost
sanitation market.
Past subsidy approaches to sanitation still result in residents expecting some form of hand out, even
in urban settlement areas. Overcoming this thinking is a challenge for World Vision. During triggering,
in response to community anger about a lack of subsidies, World Vision carefully explains the CLTS
approach. The NGO does not subsidize toilet construction, except for households with special needs, and
the cost of transport for bulk orders. Still, in urban areas with a long history of subsidized projects and
residents working in the cash economy, there is a persistent perception by some that World Vision should
provide construction materials for free and stipends for WASH Action Committee members.
Another challenge is land tenure and physical space for on-site sanitation. Most informal settlers lack land
tenure, instead receiving provisional permits.
The settlements were originally triggered during a visit by Kamal Kar of the CLTS Foundation to Honiara
in March 2013. Progress has varied in each settlement depending on the specific context of each. For
instance, in the relatively homogeneous settlement of Lord Howe, social cohesion is high, but cramped
living quarters, insecure land tenure, and strong cultural practices of defecating in the sea retained from
the residents home island means that open defecation persists. In response, World Visions programme
initially focuses on hygiene while appropriate sanitation solutions are sought. In the settlement of Wind
Valley, a sub-set of the larger White River settlement, there is moderate social cohesion as most people
are from the same place, and there is sufficient space for people to construct their own on-site sanitation
facilities. Because of this, Wind Valley is making better progress towards their ODF status, and prepared
for an ODF declaration date of September 2015.
Sanitation behaviour is very slow to change and the elimination of open defecation and the upgrading of
sanitation is difficult to influence. Settlers who have come from rural areas may be the slowest to give up
defecating in the open.
46 ibid.

Latrine slabs for sale at the Honiara City Council
White River Settlement White River Settlement

New latrine Collecting rainwater for
flushing and handwashing.

VIET NAM

Viet Nam: Case study Testing Viet Nams ODF criteria and cer-
tification process
Viet Nam has given a lot of thought to its ODF certification system. The Ministry of Health and other
sector partners, with technical assistance from UNICEF, have developed comprehensive guidelines on
the criteria for ODF, and the protocol for verification and certification.
Many countries have established criteria for reaching ODF only at the village level; Viet Nams ODF
monitoring system is multi-level and includes detailed procedures for ODF villages, as well as aggregated
ODF verification at the commune and district levels.
The guidelines were developed by reviewing and learning from several other countries outside of the
region, namely Ethiopia, Ghana, Nigeria, Sierra Leone, and Uganda. These other countries were reviewed
for how they have developed their ODF criteria, and the content of their guidelines. Viet Nams draft
guidelines were then tested in seven provinces where UNICEF is supporting the Ministry of Healths
Vietnam Health Environment Management Agency (VIHEMA) to implement CLTS through provincial
Centres for Preventive Medicine. The guidelines have been reviewed following this practical application.
What does it mean to be ODF in Viet Nam?
For a village, the ODF criteria means a village has achieved the most basic changes of stopping open
defecation and promoting handwashing. Fish pond latrines and overhanging toilets, buckets and barrels
are all excluded from the guidelines definition of a latrine and are considered as open defecation.
For a commune to be certified as ODF, all the villages and hamlets within its jurisdiction should have
already been certified as ODF; along with all main school branches and health centres having functional
and used WASH facilities.
The criteria for district ODF is that all the villages and hamlets within the district stop open defecation
and have handwashing in place. In addition, all the schools and health centres within the district have
functional WASH facilities that are in use.
The criteria for each administrative level is shown in Figure 1.
Figure 1: ODF criteria at village, commune and district levels
Village ODF Commune ODF District ODF
The entire village stops open defecation, All villages and hamlets in the The entire district stops
every family and its members use latrines. commune achieved Village open defecation.
ODF.
Faeces of infants/children are disposed into All villages and hamlets
latrines. The commune has volunteers in all communes have
representing each of its villages achieved Village ODF.
At least 90% of households have latrines;
in a commune monitoring
and the remaining 10% of households share All communes in the
group to assist the head of the
latrines with others. district have achieved
commune and the Commune
Commune ODF.
No trace of faeces found in the village. Peoples Committee to promote
and monitor sanitation and 100% of health stations,
At least 75% of households have an
hygiene. district health centres
improved pit latrine.
and schools (main school
100% of health centres and

At least 70% of households have branches) in the district
schools (main school branches)
handwashing places with a cleansing agent have access to water,
in the commune have access
(soap or a soap substitute). hygienic latrines and
to water, hygienic latrines and
handwashing areas with
Village establishes community monitoring handwashing facilities that use
cleansers.
volunteers. a cleansing agent.
The community has rules and regulations
against open defection behaviour.

Village verification and certification process
What the guidelines embed in the verification process is clear responsibilities for who does what, and
also a strict but realistic time frame for action. For example, when a village meets the criteria specified,
the leaders in the village self-declare and send an appraisal request (including completed checklists)
to the Commune Peoples Committee (CPC) for the village to be independently verified. The CPC
reviews the claim of the village within a week. After a satisfactory review of the villages ODF claim, the
commune authorities request the district authorities to verify the village for ODF certification.
Every district authority sets up an appraisal team of five to seven people including representatives
from the district health centre, commune health station, CPC, village leaders, and village health and
mass organization representatives. The appraisal is made on all households in the village, with village
ODF status awarded as follows: (1) recognized; (2) recognized with certain items to be completed; or (3)
unrecognized. The district authority organizes appraisal within 15 working days of request and sends their
report to the village and commune authorities with their recommendation, with a copy to the Provincial
Peoples Committee (PPC).
If successful, a village is awarded ODF status within one month from the appraisal. The ODF recognition
certificate is then issued by the District Peoples Committee (DPC).
ODF award ceremonies are a serious part of the certification process. According to the ODF Guidelines:
The ceremony should be solemn, meaningful, effective and economical to express residents pride in
their achievements, raise awareness and commitment of local people to maintain the ODF status and
effectively manage environmental sanitation, and personal hygiene to improve public health. Groups
of villages may be granted their ODF certificates at one time to accelerate the process, especially
combining cultural or festival activities or other important events. The ceremonies are an opportunity for
recognition by commune and district level government and other organizations, but the attendance of
representatives from the PPC and/or Provincial Health Centre give the event gravity. The ceremony often
includes speeches and presentations, arts performances, games and competitions, but most importantly
they feature a public declaration of commitment from village residents to uphold the ODF status.
Commune and district verification
Commune and district verification is done on a sample basis. Where the commune claims to have
achieved ODF status, at least 15 per cent of total villages in the commune are randomly selected to
undergo re-verification. Out of the selected villages for re-appraisal, the verification team will randomly
select a sample of 10 per cent of the total households. The WASH status is also verified for 100 per cent
of main school branches and health centres. Similarly, a sample of 15 per cent of the communes will be
drawn from which to verify district level ODF.
Both the commune and district level verification processes have clear lines of responsibility and time
frames for the execution of the checks and certification.
Sustaining ODF
Due to resource constraints it is difficult for district authorities, under guidance of the provincial
authorities, to frequently verify the sustainability of ODF at village level. It therefore falls to the CPC to
maintain the status by enforcing a commune and village resolution and by using a set of volunteers/
leaders, who may serve as the members of the community monitoring group to continually promote
sanitation and hygiene.
The long-term continuation of village and commune ODF status is checked. This task falls to the DPC
which conducts a review after three years. For district level sustainability of an ODF status, the PPC
checks ODF after five years of certification. In either case the ODF certificate may be withdrawn if
commune and village authorities fail to maintain the ODF status.

How well have the guidelines worked?
The pilot of Viet Nams ODF guidelines has provided valuable testing of how guidelines on paper are
practically implemented in the field. Several provincial Departments of Health are using the verification
and certification process, and NGOs such as ChildFund and Plan International are also using the
guidelines, with more sector partners interested to join the process.
Initially, Viet Nams draft guidelines had two levels of ODF ODF1 and ODF2 depending on the level of
coverage of hygienic latrines and other criteria but this was complex and the initial focus is on getting
the basics right.
The latest guidelines have been refined with further consultation with VIHEMA/Ministry of Health and
other sector partners in Viet Nams sanitation working group.
One feature of the guidelines which supports their implementation, is the recognition of the ancillary
support needed for an ODF verification system. Other countries have good processes but sometimes
overlook the responsibilities or budget to carry out the processes. In Viet Nam, steering committees or
working groups under Ministry of Health and chaired by VIHEMA, at province, commune and district
level and are responsible for overseeing the verification processes. The steering committees are provided
with documents and instructions to implement appraisal and the recognition of ODF communities. These
steering committees ensure there are skills, responsibilities and budget for all ODF certification, including
training, planning, scheduling, transport, stationery, communication, and mass media all the practical
items needed to support ODF certification.
Whats next?
Following the testing of the guidelines in seven provinces over one year, the guidelines have been revised
with input from the practicing provinces, NGOs, the World Bank Water and Sanitation Program, and
UNICEF. Now the guidelines need to be finalized by partners, authorized by Government, and then utilized
by all.

UNICEF would also like to acknowledge the financial support from
Bill & Melinda Gates Foundation (BMGF), the Department for
International Development (DFID) and Government of Australia
through the Department of Foreign Affairs and Trade (DFAT) for
completing and publishing this document.
UNICEF East Asia and Pacific Regional Office (EAPRO)

19 Phra Atit Road
Bangkok 10200 Thailand
Tel: (66 2) 356-9499
Fax: (66 2) 280-3563
E-mail: eapro@unicef.org
www.unicef.org/eapro

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Second Review of

Community-Led Total Sanitation

Community-Led Total Sanitation

i East Asia and Pacific Regional Report

2016 UNICEF/EAPRO East Asia and Pacific Regional Office,

All cover photos UNICEF

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Wivina Belmonte Chander Badloe

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Data sources and notes

Country-specific data: from interviews and contributions from country teams.

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4 Global and regional update 7

ANNEX 1: Country CLTS overview 44

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EASAN East Asia Ministerial Conference on Sanitation and Hygiene

CATS Community Approaches to Total Sanitation

CBO community-based organization

CLTS Community-Led Total Sanitation

DFAT Department of Foreign Affairs and Trade

DHS Demographic and Health Survey

DSWD Department of Social Welfare and Development (the Philippines)

iDE International Development Enterprises

INGO international non-governmental organization

IUWASH Indonesian Urban Water, Sanitation, and Hygiene

LGU local government unit

MICS Multiple Indicator Cluster Survey

MDG Millennium Development Goal

MoH Ministry of Health

NGO non-governmental organization

ODF open defecation free

PAKSI Community Action Plan for Sanitation and Hygiene (Timor-Leste)

PhATS Phased Approach to Total Sanitation

RWSSH Rural Water Supply, Sanitation and Hygiene

SNV Netherlands Development Organisation

UNICEF United Nations Childrens Fund

USAID US Agency for International Development

WASH Water, Sanitation and Hygiene (Sector)

WHO World Health Organization

WSP World Bank Water and Sanitation Program

ZOD Zero Open Defecation

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1 Assuming an average village size of 1,500 people.

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Promising new developments and trends in CLTS include:

However challenges remain which need to be addressed:

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The following are additional observations regarding the improvement of CLTS.

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Update the 2012/2013 Regional Assessment:

Develop comprehensive country-specific case studies:

Country CLTS status updates

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Each country CLTS status update included the following sections:

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Focus on ODF progress

Country-level CLTS analysis

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4.1 UNICEF CATS

The findings are across four areas:

The impact of CATS is constrained by the following:

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